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BY: JEFFERY RAMIREZ, PhD, PMHNP

The passage of the Affordable Care Act in 2010 gives millions of U.S. citizens access to health care. The ACA builds on prior legislation, allowing people with mental illness access to services by expanding on the Mental Health Parity and Addiction Equity Act of 2008.¹ It is estimated that 8 million U.S. citizens are enrolling in health insurance exchanges, and an additional 3 million will have insurance coverage through Medicaid expansion programs.²

Most of us who work in the mental health professions are supportive of this expansion, but we worry about the workforce needed to respond to the millions of people accessing services. In order to provide quality and safe mental health treatment, a number of challenges must be addressed, including inadequate numbers of psychiatrists and psychiatric nurse practitioners.³ An estimated 77 percent of U. S. counties are reporting a significant shortage of professionals who can prescribe and manage medications.⁴

The prevalence of people suffering with mental illness is a significant public health issue. Major mental illnesses such as schizophrenia, bipolar disorder and depression are costly to individual care providers, insurers and government agencies, and they are devastating to both the person and his or her family. According to the National Institute of Mental Health, neuropsychiatric disorders are the leading cause of disability.⁵ NIMH categorizes mental, behavioral and neurological disorders in this data, with the largest portion being in mental and behavioral categories.

The National Alliance on Mental Illness estimates 1 in 5 adults suffers from some form of mental illness ranging from schizophrenia and bipolar disorder to depression and anxiety.⁶ Even more alarming are the millions of children suffering from mental illness and substance-use disorders. According to 2013 data from the Substance Abuse and Mental Health Services Administration, 2.6 million youths aged 12-17 had a major depressive episode, and 3.3 million received treatment or counseling for emotional or behavioral issues.⁷

Mental illness often is complicated by chronic conditions such as cardiovascular disease, obesity, diabetes and hypertension. Additionally, people suffering from chronic mental illness die on the average of 25 years earlier than those without mental illness.⁸

Furthermore, SAMHSA reports the U.S. spent $3.5 trillion in 2014 on health care, and 6.9 percent of that was on mental health services.9 The cost of mental health and substance abuse treatment continues to increase. Since 1986 there has been a fourfold increase in spending per person. The amount is expected to increase to sixfold in the near future.¹⁰

The consequences of untreated mental illness are significant. They include high rates of incarceration, homelessness, drug and alcohol use, hospitalization, emergency room visits and suicide rates.

One of the major concerns for people with mental health issues is accessing mental health care professionals who have the knowledge and skills to provide comprehensive care, including preventive strategies, primary mental health, psychotherapy and medication management. Psychiatric mental health nurse practitioners (PMHNPs) are trained in the competencies that could help meet the needs of this population. Unfortunately, our role is poorly understood, regulatory barriers have limited the full scope of our practice and, as a result, there is a shortage of the specialty among advanced practice nurses.¹¹

HISTORY
In 1954, Hildegard Peplau, MA, EdD, started the first graduate program granting a master's degree at Rutgers University in New Jersey for clinical nurse specialists in psychiatric mental health nursing. Peplau was a visionary who identified nurses as knowledge workers — in other words, she recognized that with proper education and training, psychiatric nurses could offer mental health care to patients, including independent individual and group psychotherapy. Peplau advanced the nursing profession by changing the role not only of psychiatric nurses, but of all graduate-level nurses, from supportive tasks to roles like counselor, educator, administrator and clinical expert.

State governments regulate the scope of practice rules for licensed registered nurses and advanced practice nurses. Some states recognize clinical nurse specialists as advanced practice nurses. In the state of Washington, for example, clinical nurse specialists are permitted to operate solo practices providing psychotherapy to individuals, couples and families.¹² Washington also is one of many states that allows a CNS to bill fee-for-service and third-party payers.

Clinical nurse specialists were well established as advanced practice nurses in 1965, when public health nurse and educator Loretta Ford at the University of Colorado was developing the first pediatric nurse practitioner program.¹³ Unlike clinical nurse specialists, nurse practitioners function under the supervision of a physician, and Ford's program was intended to fill gaps in pediatric care because of physician shortages. The curriculum focused on health promotion and disease prevention.

As time went on, the role of nurse practitioner began to establish the concept of advanced practice nursing, but some confusion remained among the public, third-party payers and hospital administrators about job descriptions, certification and licensing — primarily, who did what. The role of the psychiatric CNS was particularly confusing, because their functions were more in line with those of the nurse practitioner; they had independent autonomy and could open a solo practice as well as prescribe medications. However, their education, licensing and certification processes were more like those of a CNS.

A CREDENTIALING SHIFT
After several years of controversy and debate, the American Nurses Credentialing Center (ANCC) decided in 1999 to offer PMHNP exams to nurses qualified to be certified and credentialed as such.¹⁴ The psychiatric CNS exam was retired. All board-certified PMHNPs are prepared to provide psychiatric care, including prescribing psychotherapy and medications, to children, adolescents, adults and geriatrics suffering from mental illness and substance abuse. New graduates enter the field as novices and need time to specialize in the population they choose to work with, such as children or geriatrics.

Nurses opting to pursue a PMHNP credential must have a current registered nursing license and hold a bachelor's degree from an accredited school. Many nurses who return to further their education already have years of experience. For example, all registered nurses with a bachelor's degree have at least four years of education. As registered nurses, they have gained competencies in basic interpersonal and therapeutic communication, assessment, diagnosis, administration of medications, critical thinking and the development of interventions and plans of care. The PMHNP program builds on the foundation of the basic nursing education and leads toward a master's or doctoral degree. All PMHNPs are required to complete courses in psychopharmacology, psychiatric assessment and diagnostic criteria. There also is a requirement for PMHNPs to have knowledge and skills in two psychotherapy modalities such as cognitive behavior therapy and interpersonal therapy.

The American Association of Colleges of Nursing requires a minimum of a master's degree in psychiatric mental health nursing to take the board certification exam. Most U.S. states require this certification in order to be licensed as an Advanced Practice Registered Nurse.

SKILLS AND COMPETENCIES
Although there is only one board certification for PMHNP, which is administered by ANCC, there are three groups — the National Organization for Nurse Practitioner Faculties, AACN and ANCC — that determine the skills and competencies required for PMHNPs. Curricula are built based on the recommendations and standards set by these organizations to help standardize competencies.

PMHNPs are prepared to treat people in need of primary mental health services. The typical clinical practice settings in which we find ourselves are:

• Crisis intervention and psychiatric emergency services
• Acute inpatient care
• Intermediate and long-term care
• Partial hospitalization and intensive outpatient treatment
• Residential services
• Community-based care
• Assertive Community Treatment (ACT)*

There are opportunities for PMHNPs to specialize in a particular area of practice, especially in response to changes in the health care system. In 2014, the American Nurses Association Scope and Standards of Practice for Psychiatric Mental Health identified the following specialties that could benefit from PMHNPs' skills and knowledge:

• Integrative programs (treatment for both mental disorders and substance use disorders)
• Telehealth
• Forensic mental health
• Disaster psychiatric mental health nursing

VIOLENCE AND SUICIDE
Suicide is a major public health issue, and all PMHNPs must be proficient in assessing patient risk for suicide and for developing appropriate interventions to keep the patient safe, including developing a safety plan or referring the patient for inpatient hospitalization. Violence towards others also is a significant risk, and PMHNPs must be able to assess, intervene and understand the laws regarding mandatory reporting.

During a patient's initial assessment, their mental health symptoms, risk and other disorders are included in the workup. During a typical day, for example, I routinely order and interpret pertinent laboratory and other diagnostic studies such as a complete blood count and comprehensive metabolic, thyroid, liver and renal panels. The purpose is to rule out any disease process that may be causing or exacerbating the mental health symptoms.

What's more, understanding the functional status of these body systems is important, because it will help me select or adjust the most appropriate medications. This is why psychiatric mental health nurse practitioners are required to take advanced pathophysiology, advanced health assessment and advanced pharmacology courses.

Once I finish the assessment, I develop a treatment plan that may include medication management, psychotherapy, referral to a provider to help manage other health conditions, and medication management, for which there is strong demand.

CURRENT TRENDS
As long ago as 2003, a pivotal report set the foundation for fixing the American mental health system. The President's New Freedom Commission on Mental Health report pointed out the stigma of mental illness, lack of insurance coverage for mental health conditions and prevention strategies.

Since then, the recovery movement has gained acceptance and focused on decreasing stigma, increasing person-centered care, improving the lives of people with mental illness, and most importantly, instilling hope that people with psychiatric disabilities can recover. The philosophy and goals of psychiatric mental health nursing practice is a perfect match.

Health care organizations are using PMHNPs to prescribe, adjust and manage psychiatric medications for people in need. This practice requires specialized knowledge integrating assessment data, diagnosing, understanding both the psychiatric and general pharmacology principles to avoid adverse reactions and drug-drug interactions. PMHNPs are trained for the work, but they are trained for more than this: They are educated, licensed and skilled as psychotherapists.

Complex as it is, psychotherapy is a psychiatric mental health nurse practitioner competency, and it requires significant introspection, self-awareness and ability to build interpersonal relationships as well as choose the most appropriate intervention, which could be cognitive, behavioral or existential therapy. There is growing concern among many nurse practitioners that the need for clinicians to manage psychiatric medications will obscure the PMHNP's skills and training in other important areas.

CONCLUSION
As the passage of the ACA has given millions of U.S. citizens access to health care, it has placed growing demands on mental health care providers.15 Growing need for mental health services, along with a declining number of psychiatrists, increases the market for PMHNPs.

PHMNPs are prepared to provide independent and autonomous mental health care and treatment, as well as work in a team with a psychiatrist. This allows psychiatrists more time to spend with more complex and higher acuity patients.

The rapidly changing field of health care requires innovation and nimble use of our strengths to develop new treatment delivery models that integrate various services and decrease fragmentation. PMHNPs are educated in five different sciences — medicine, neuroscience, psychiatry, relationships science and psychotherapy — making them a fertile source for delivery of treatment in the patient-based continuum of care.16

JEFFERY RAMIREZ is associate professor, Department of Nursing, Gonzaga University, Spokane, Washington.

NOTES

1. Babatunde Ogundipe et al., "Remaking the American Health Care System: A Positive Reflection on the Affordable Care Act with Emphasis on Mental Health Care," Journal of Health Care for the Poor and Underserved 26, no. 1 (February 2015): 49-61.
2. Robyn R. Golden and Matthew R. Vail, "The Implications of the Affordable Care Act for Mental Health Care," Generations: Journal of the American Society on Aging, posted Dec. 11, 2014. www.asaging.org/blog/implications-affordable-care-act-mental-health-care.
3. Elizabeth Reisinger Walker et al., "Psychiatric Workforce Needs and Recommendations for the Community Mental Health System: A State Needs Assessment," Psychiatric Services 66, no. 2 (February 2015): 115-17.
4. Michael A. Hoge et al., "Mental Health and Addiction Workforce Development: Federal Leadership Is Needed to Address the Growing Crisis," Health Affairs 32, no. 11 (November 2013): 2005-12.
5. National Institute of Mental Health Statistics, "U.S. Leading Categories of Diseases/Disorders," www.nimh.nih.gov/health/statistics/disability/us-leading-categories-of-diseases-disorders.shtml.
6. National Alliance on Mental Illness, "Mental Health by the Numbers." www.nami.org/Learn-More/Mental-Health-By-the-Numbers.
7. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings (Rockville, Maryland: Substance Abuse and Mental Health Services Administration, 2014). www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf.
8. National Alliance on Mental Illness, "Mental Health by the Numbers."
9. SAMHSA, Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings.
10. SAMHSA, Results.
11. Catherine Dower, Jean Moore and Margaret Langelier, "Is It Time to Restructure Health Professions Scope-of-Practice Regulations to Remove Barriers to Care," Health Affairs 23, no. 11 (November 2013): 1971-76.
12. Laura C. Hein and Kathleen M. Scharer, "A Modern History of Psychiatric – Mental Health Nursing," Archives of Psychiatric Nursing 29, no. 1 (February 2015): 49-55.
13. Ruth Perou et al., "Mental Health Surveillance among Children — United States 2005-2011," Mortality and Morbidity Weekly Report 62, Supplement, no. 2 (May 17, 2013):1-35.
14. Kathleen Wheeler and Judith Haber, "Development of Psychiatric-Mental Health Nurse Practitioner Competencies: Opportunities for the 21st Century," Journal of the American Psychiatric Nurses Association 10, no. 3 (June 2004): 129-38.
15. Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health (Washington, DC: The National Academies Press, 2010). https://iom.nationalacademies.org/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.
16. Kathleen R. Delaney, "Psychiatric Mental Health Nursing: Why 2011 Brings a Pivotal Moment," Journal of Nursing Education and Practice 1, no. 1 (2011): 42-50.