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Mental Health Nursing


Co-morbidity is a term describing the presence of two or more diseases in the same individual (Drake et al., 1996). These diseases may be psychiatric or medical conditions, as well as drug abuse related disorders. The diseases can occur simultaneously or may come in sequence. In this paper for instance, we analyze the case of Kirsten Green, who has a history of schizophrenia and drug abuse. Schizophrenia is a mental disorder that is characterized by disintegration of emotional responsiveness and the thought process, and the occurrence of this disorder together with drug abuse in Kirsten’s case, is what is refereed to as co-morbidity. However, it is important to note that the presence of two illnesses in one individual may not necessarily mean that one is the cause of the other, though this can also happen. Delivering treatment to people suffering from both mental disorders and substance abuse is a major problem to the health care practitioners. In addition, co-morbidity is usually linked to poor treatment results, high service utilization and severe illness course. This however, presents major challenges when it comes to identification, management and prevention of people suffering from co-morbid disorders (Drake et al., 1996). This is worsened by the fact that treating this disorder requires a couple of time, and as research indicates, the lifetime prevalence rate among patients suffering from schizophrenia is about 50 per cent, while current substance abuse estimates vary from 20 to 65 per cent (Drake et al., 1996). This paper will focus on the community management of co-morbid psychiatric disorders.

Nursing assessment and management

Assessment and management of medical predicaments pose a critical obstacle to sufficient care of patients with co- morbid psychiatric disorders. Co-morbid occurs when two disorders occur con-currently in the same individual. According to research, drug abuse and other mental illness are frequently co-morbid (Chambers et al, 2001). In our case study, Kirsten Green has a history of schizophrenia and drug abuse. This co-morbidity may be as a result of:

  • Drug abuse causing the mental illness

  • Schizophrenia leading to drug abuse

  • Mental illness and drug abuse may be influenced by other risk factors

Nursing assessment and management is essential in such a case and it will focus on establishing the patient’s signs and symptoms, risk of self injury, the extent of impairment in her thought process, violence towards other individuals and availability of support systems (Angermeyer, 2000).

Objectives of the assessment

It is apparent that, Kirsten is suffering from a critical problem which requires assessment and management. Some of the objectives of this assessment will encompass:

  • Analyzing the concepts and challenges associated with co-morbid

  • How to treat and prevent co-morbidity in patients thus prevent future violence

  • Implications of co-morbidity for service delivery

  • Establishing a comprehensive community treatment and management plan

Content and approaches to the assessment

It is true that, co-morbid disorder is linked with high rates of violent behavior. As a result, mental health services have a role of reducing such behaviours for their patient’s sake as well as the whole community (Watkins et al, 2001). In our case, Kirsten in her psychosis condition is seen to involve herself in assaultive behaviours and prostitution. It is also clear that, this was her third admission in the past year. In order to instigate management of her co-morbid situation, various approaches to the assessment will be used.

The approach to the assessment will involve interviewing the patients and will focus on establishing the patient’s signs and symptoms, risk of self injury, the extent of impairment in her thought process, violence towards other individuals and availability of support systems (Chambers et al., 2001). Such an interview will be more successful if there is presence of a friend or family member as more information concerning family history, episodes of psychotic symptoms, and cases of violent behaviours can be obtained. Nevertheless, in our case, report shows that, Kirsten is homeless and unkempt which implies she is neglected that the interview may be carried solely.

  1. Assessing mood and cognitive state

While assessing the cognitive state of the patient, various signs and symptoms will be considered. They include: ideas of reference, manifestation of feelings of unreality, lack of manifestation of feelings, expression of odd ideas, pronounced paucity of thoughts and speech, and language content. Other patient inquiries regard the current stressors that can precipitate a psychotic condition in the patient having a thought disorder, and signs of impending relapse. Such signs may include: mood changes, somatic complaints, and disturbed sleep cycle.

  1. Assessing the likelihood for violence

In this case, the likelihood for violence will be assessed and will involve inquiring about various aspects including: the history of the patient’s violent behaviours, social isolation, auditory hallucinations, medication noncompliance, associated substance abuse, and feelings of hostility (Soyka, 2000).

  1. Assessing social support

In nursing assessment, availability and responsiveness of an existing social support systems and the patient’s responsibility in the family and in the community as a whole are essential factors. It is true that, families who have patients suffering from co-morbid psychiatric disorders usually face major problems. In many circumstances, these families tend to neglect these patients as they feel that they are a burden. In addition, the community also tends to neglect these patients and they are left on their own thus worsening their current state. Most mental health services, lacks the will while some are not well equipped to deal with co-morbid patients. As a result, this rejection and lack of social support makes the patient feel extremely isolated therefore, worsening their condition. In our case, Kirsten is suffering from lack of social support. Her family, friends and the community at large seems to have neglected her. This as a result has contributed to her extreme condition, and though she has been admitted in the psychiatric unit for three consecutive times in the same year, the treatment seems to have no positive outcomes.

  1. Assessing knowledge

This involves assessing the patient’s knowledge regarding schizophrenia and drug use, their treatment and likelihood for relapse. Management and treatment can only be encouraged when the patient understands the basis of the co-morbidity, signs of relapse or recovery, and their responsibility in treatment. In our case, understanding this will help Kirsten greatly as she will be able to comply with the medications due to the motivation offered, and at the same time quit her drug use habits (Watkins et al., 2001).

Concepts and Challenges associated with co-morbid mental illnesses

A lot of literature has been generated regarding how to deal with patients suffering from co-morbid disorders. Patients suffering from both schizophrenia and drug abuse appear to be problematic as their treatment initiatives are particularly associated with various negative outcomes. A research study conducted in the United States found that patients who suffered from both drug and substance abuse and schizophrenia showed increased levels of non-compliance to medication, suicidal behaviour, depression, psychosocial problems, required high levels of medication, homelessness, placed a higher burden on their relatives and re-hospitalization, compared to those who suffered from schizophrenia exclusively (Drake, et al. 1996). This condition is evident from the case study, since Kirsten exhibited such behaviours as assaulting behaviours, and homelessness. Conversely, in another Australian study conducted by Fowler et al. (1998), patients with schizophrenia and drug and substance abuse, tended to have an increased rate of indulging in criminal behaviours, earlier onset of mental illness and increased symptomatology. However, several demonstration and pilot projects have provided mixed outcomes, but researchers appear to have a consensus regarding the requirements for effective treatment despite the negative outcomes that are often experienced.

Most patients with co-morbid disorders suffer from a generalized anergia and avolition due to medical side effects, hypodopaminergia in the frontal cortex or other biological, psychological and social factors, which contribute to the negative symptoms (Blanchard et., al.1998). Therefore, they may not have the initial drive to establish the complex behavioral routines they need to abstain from the drug abuse. The other negative symptom is anhedonia, which may consist of the experience of positive effect, hence limiting the ability of the patient to experience positive reinforcement and pleasure in the absence of drug abuse and restricts the patient’s appraisal of the positive effects of abstinence. Extensive data documents that patients suffering from schizophrenia can acquire new information and learn various skills, but little evidence exists to support the fact that they can apply the acquired skills in the community (Drake, et al. 1996).

The other reason why health care practitioners find it difficult to deal with patients suffering from schizophrenia and drug abuse is that patients with this co-morbid disorder have prominent deficits in memory, attention and higher level of reasoning exhibiting characteristics such as abstract reasoning (Hunt et al., 2002). Moreover, they also possess deficits in maintenance of set, described as the ability to sustain focus on a specific goal, and the ability to apply the previous experience to control the current behaviour. They also depict profound deficits in the ability to make social judgments and solve problems (Carey & Correia, 1998). This makes it difficult to administer treatment of such types of patients since they lack the ability to maintain focus as well as memory problems whereby it makes them difficult to take of themselves. Considering the case of Kirsten for example, she has been in hospital for three times being admitted with the same medical condition, something that could be easily solved if she followed the corrective medication as per the doctor’s prescriptions. It is even feared that she could stop taking the anti-psychotic medication since her she suffers from other symptoms such as memory deficit and attention deficit that could impede her from taking the medication.


After completing the assessment process, management and treatment actions will be taken which will oversee the achievement of the assessment objectives. In tackling the above assessment problems in our patient, it is important to apply various skills and knowledge. In the case of disturbed thought process, it is good as a care provider to focus on reality, convey acceptance for patients necessitate for false belief but show her that you do not agree with her belief, avoid arguing with the patient and ensure that, you keep all promises. In the case of social isolation, as the care giver, I would offer to be with the patient to offer social support, reinforce the patient positively to interact with other individuals, which will reduce the feeling of isolation, and also show unconditional regards to the patient.

Various approaches to the treatment of co-morbid patients are generally provided through the employment of multidisciplinary treatment teams, who offer outreach, stage wise treatments and comprehensive services (Fortinash & Worret, 2003). The importance of outreach services is to encourage the patients, as it is clear that, most of them are demoralized and are therefore reluctant to comply with medication. On the other hand, comprehensive services are essential as recovery entails building skills and helps the patients to pursue a significant life rather than just treating the illness or managing the symptoms. Through help and support from treatment providers, Kirsten can be assisted to pass through four essential stages of disease management (Watkins et al., 2001). These stages include:

  • Engagement: this encompasses building a more trusting treatment association between the care provider and the patient. In this case, the patient will feel more motivated and included in the society thus engaging in treatment as required.

  • Persuasion: it involves development of motivation, which assists in managing both the condition and pursues recovery.

  • Active treatment: this entails developing required skills and support for illness treatment and recovery.

  • Relapse prevention: many co-morbid patients most likely reverse to their initial habits. To manage this, caregivers should establish strategies which avoids and minimizes the consequences of relapses.

Training is also an essential management action which allows schizophrenia patients and drug users to modify their behaviours to the better (Fortinash & Worret, 2003). Through training, patients receive positive social reinforcement which allows them to modify and work towards changing their behaviours.

Community treatment and management plan for Kirsten

Research documents that self-direct and motivation are key to the treatment and management of patients with co-morbid disorders since treatment does not prove to be the best remedy for co-morbidity. However, the following step-by –step approach provides a plan that could be applied to treat and manage Kirsten’s condition.

Step 1: The initial step of the treatment plan requires that the entire treatment team including drug and substance abuse counselors and the consulting specialist convene to review and integrate information from all perspectives and sources such as the treatment goals in order to come up with a list of the targeted interventions. However, these goals and intervention should be often reviewed and modified while the patient progresses with the treatment.

Step 2: The focus in this step is to engage the patient by developing a strong treatment agreement and the collaborately agreed on treatment goals in order to stabilize drug abuse and start addressing co-morbid disorders, and in this case, schizophrenia, in the patient. If possible, motivation-enhancing techniques together with other empirically supported therapies such as Cognitive Behavioral Therapy should also be used. Apart from the group therapy and the counseling services, relatives have to take an active role in the treatment plan.

Step3: It is best to start by substance abuse treatment before initiating the treatment for the co-morbid disorder. However, the clinician must weigh the threat to potential drug medication interactions against the possibility that untreated psychiatric disease will prevent treatment engagement or interfere with the attainment of abstinence. Once substance abuse treatment has been initiated, the clinician should develop a plan for standard monitoring and exchange of information regarding compliance with the substance abuse treatment. This has to be scheduled for at least a weekly session.

Step 4: If the targeted symptoms for substance abuse and co-morbid disorder treatment do not improve within the initial two months of the treatment program, clinical deterioration or consequently cases of drug abuse escalation, then it is necessary to change medication and reassessing the diagnosis, or increase the level of treatment frequency (Hunt, et al. 2002).

Step5: In this step, it is necessary to talk with the patient about strategies that could help prevent relapse and the need to adhere to the treatment plan. Lack of treatment compliance and frequent follow-ups increases the probability for relapse and deterioration of the psychiatric disorder. Cases of relapse are often high and it is therefore necessary to have comprehensive talks about how this could be prevented, and if possible, a workable plan for predicting and managing relapses should be developed to ensure continued care and treatment for the patient is in place. In the same way, primary care physicians should develop workable plans for monitoring and assessing the stability of psychiatric co-morbidity (Hunt, et al. 2002). For instance, the patient should be encouraged to take part in self-help support groups as a strategy for relapse prevention.

A strict follow up of these steps will help deal with patients suffering from co-morbid disorders since it provides the necessary measures that could be considered while administering the treatment as well as strategies that could be implemented to prevent relapses.


Co-morbid is a common complication and is linked with serious adverse effects. In our case, Kirsten, who is suffering from both schizophrenia and drug abuse requires immediate medical attention before her condition deteriorates to unmanageable levels. Her condition can be linked to lack of social support thus, she feels isolated and this even accelerates her condition more. This can be linked to the fact that, although she has been admitted to the psychiatric unit thrice in the same year, no improvements have been recorded. With good assessment and intervention, together with adequate social support both from health care providers, individuals and from the community in general, Kirsten can be assisted in recovering from her current condition.


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