Roy Simpson, our information technology columnist, cited an interesting statistic from the World Health Organization, the World Bank, and Harvard University from their Global Study of Disease conducted a decade ago. It indicated that fully 8 of the 10 leading causes of disability are based in mental illness.1 The National Institutes of Mental Health tell us that an estimated 26.2% of Americans aged 18 and older-about 1 in 4 adults-suffer from a diagnosable mental disorder in a given year.1 When applied to the 2004 US Census residential population estimate for people aged 18 and older, this figure translates to 57.7 million people.2 Even though mental disorders are widespread in the population, the main burden of illness is concentrated in a much smaller proportion-about 6%, or 1 in 17-who suffer from a serious mental illness.1 In addition, mental disorders are the leading cause of disability in the United States and Canada for people aged 15-44.3 Many people suffer from more than one mental disorder at a given time. Nearly half (45%) of those with any mental disorder meet criteria for 2 or more disorders, with severity strongly related to comorbidity.2
Couple this with the drug abuse epidemic and we understand the challenge of dual diagnosis, that is, a mental health diagnosis and a substance abuse problem. We find these patients not only in our behavioral health units but more often in our emergency departments and our general patient care units. They are unique complex patients when coupled with a medical need.
Of particular worry is the methamphetamine epidemic. This has invaded our heartland most particularly and every state. In 1999, more than a million Americans used methamphetamine, more than those who used crack and almost 3 times as many as used heroin.3 It is cheap to make and rural populations have been especially hit hard.
Another unspoken but overriding issue that all nurse executives have come to deal with on a day-to-day basis and as part of the job is the patients they have managed as a result of deinstitutionalization. Former patients by and large did not integrate into society and become functional. Instead they became the homeless and developed physical as well as emotional problems far more profound than the nurse executives could have ever imagined. They now end up in healthcare organizations needing an intensity of care that is a burden on the system. Upon discharge, they are difficult, if not impossible, to place.
Can we as leaders develop a safe solution for their placement that is cost-effective and therapeutic? So many challenges confront us.
Just a look at 2 more mental health challenges-autism and Alzheimer's disease (AD)-will give us an idea of how much more strained our resources are going to be. AD affects an estimated 4.5 million Americans. The number of Americans with AD has more than doubled since 1980.4 Someone develops Alzheimer's every 72 seconds, according to a new Alzheimer's Association report.
The Alzheimer's Association today reports that in 2007 there are more than 5 million people in the United States living with AD. This number includes 4.9 million people older than 65 and between 200,000 and 500,000 people younger than 65 with early onset AD and other dementias. This is a 10% increase from the previous nationwide estimate of 4.5 million.
The greatest risk factor for Alzheimer's is increasing age, and with 78 million baby boomers beginning to turn 60 last year, it is estimated that someone in America develops Alzheimer's every 72 seconds; by mid-century someone will develop Alzheimer's every 33 seconds.5
Another problem that is attacking our infants is autism. Autism is part of a group of disorders called autism-spectrum disorders, also known as pervasive developmental disorders. Autism- spectrum disorders range in severity, with autism being the most debilitating form while other disorders, such as Asperger's syndrome, produce milder symptoms.
Estimating the prevalence of autism is difficult and controversial because of differences in the ways that cases are identified and defined, differences in study methods, and changes in diagnostic criteria. A recent study reported the prevalence of autism in 3-10-year-olds to be about 3.4 cases per 1000 children.2,6
However, these numbers are out of date as they are for the year 2003. The Centers for Disease Control and Prevention released, through its Morbidity and Mortality Weekly Report, the latest revised prevalence figures for autism. The report indicates that the prevalence of autism is now 1 in 150, up from the 1 in 166 figure reported by it in January 2004.7
These children are aging and the system has nothing to offer them after age 18. Can we provide the leadership to offer alternative living solutions? Also, how can our organizations contribute to our communities to incorporate these unique individuals into the fabric of our culture? Many are gifted and are extraordinarily intelligent.
It appears that we certainly have our work cut out for us. Our authors have given us a wealth of advice. Some highlights are Weiss and Delia's article on changing mission and culture to meet patient needs. With the above-predicted changes, it is timely information and a good "how-to." They noted how their population was becoming remarkably different and needed different skill sets than their current staff could provide. They went all out and created a client-specific mission and culture. It shows how we really need to be able to turn on a dime in this time. Maxwell's article is meant for any practice setting regarding the concept of "and." Collaboration in a time of transient staff and mobility is so difficult; however, she has valuable principles to share. We can no longer afford the silos, the time to be "the nurses," and suffer from the We Are Different syndrome. It is time we and our colleagues remember why we got into this game-the focus is the patient. Valente and Wright's unique approach to recruitment is a "don't miss." It really speaks to molding to meet patient needs. They tell us how upskilling the LVNs not only met population needs but also gave the caregivers a real sense of job satisfaction. A definite bonus and retention positive!! Couple that article with Randall Hudspeth's regulatory column on advance practice nurses and think of the possibilities of the expanded services. Physicians need only understand the contribution of an NP colleague to augment their practice versus viewing them as a competitor. Another article in the same vein emphasizes the critical role of competent leadership in retention and how Herrin and Spears' organization took a long-term look at how to approach that can be a real pay off.
Phillips took the bull by the horns and shows how an organization took on the perennially dreadful problem of workplace violence. This also has a negative impact on retention. Her organization's approach has lessons for all of us and is definitely an investment in keeping our caregivers. That is a basic that we can ensure for our staff. They must also have the freedom to speak up when they feel threatened and know that they are heard.
In the same vein we heard from colleagues in Israel. Hendel and her associates address conflict management and how to improve the behavioral health of the staff through physician-nurse collaboration. This demonstrates how other countries are growing and reducing power differentials where nursing has traditionally been in a subservient role.
Last but not the least we have a new author. Fralick is a dynamic, upcoming leader. She has a rare population of pediatric behavioral health day treatment patients. They are the most fragile little ones ranging in age from 5 to 15 years. She takes on the issue of decreasing and eliminating restraints. She is able to demonstrate success. I had the pleasure of seeing this group of patients more than once and meeting her remarkable staff. Her staff is your staff. They work hard, they are serious about doing the best for their patients, and they really care. To every potential author out there I want to say, you are not too small, do not say you have nothing to write about. You are doing good things and have much to teach all of us. Please share your joys, your successes, your failures. We can all learn.
Let us hope that we leaders can respond and are up to the challenge of meeting new behavioral health population's demands. Let us hope we can be there for whatever the 21st century brings. Most of all, as we retire, let us hope there are those who are young to replace and meet all of our needs, physical and behavioral.
Ann E. J. Kobs, MS, RN, Guest Editor
President, Ann Kobs & Associates, Inc., Wheaton, Ill
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