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Psychiatric nurses also face many of the same challenges as their medical counterparts-lack of community resources, shorter hospital stays, more acutely ill patients, battles with insurance companies for compensation and a shortage of qualified RNs and other health professionals to care for an increasingly needy population.

Patients who previously may have stayed up to a year in a psychiatric hospital now are discharged from an acute care psychiatric unit within seven days. Even patients who once would have had two weeks of inpatient therapy and medications now must leave in a few days.

"We generally have an opportunity to stabilize them on medications for a few days and then they're out the door," said Marlene Nadler-Moodie, MSN, APRN, clinical nurse specialist for behavioral health at Scripps Mercy.

The lucky ones go home to families or even to their own apartments and good outpatient care, such as home health, a community clinic or a private practitioner. But many have nowhere to go, despite the best efforts of nurses to place them.

"We're spending a great deal of money on education because we have nothing else to offer," said Sulema Luna, MS, CNS, RN, director of adult, emergency room and pediatrics in psychiatrics at Harris County Hospital District, Ben Taub Hospital in Houston. Her nurses give patients resources and phone numbers, and teach them as best they can how to watch for recurring symptoms. "There's no long-term support," she said.

Some patients who are discharged to board-and-care facilities don't take their medications properly or the dosage becomes unbalanced and they end up on the streets, psychiatric nurses said. One of the greatest frustrations for hospital psychiatric nurses is a "revolving door" of patients who end up back in the hospital again and again because their families can't care for them and adequate community facilities are not available to help them.

By the time mentally ill patients are admitted to a hospital, they are usually quite ill, said Dale Cohen, MSN, CS, RN, past president of the California chapter of the American Psychiatric Nurses Association. No one questions whether someone with chest pains is admitted to a hospital or whether they proper tests and medications are administered, she said.

"But for mental health patients, the only way to get admitted is to say, 'I want to kill myself' or 'I want to kill somebody else,' " Cohen said.

Insurance companies and other payers often do not cover mental illnesses the way they do medical ones, he said. Many policies limit the amount of medication or number of therapy sessions that will be paid. Policies may cover 50 percent for treatment of mental illness, compared with 80 percent or 100 percent for physical illness.

Before physicians or nurse practitioners can prescribe newer medications that work faster and have fewer side effects, some payers require they first prove patients haven't responded to older medications that have side effects.

These requirements are devastating for people who need medications or therapy for an indefinite period of time and can't afford to pay, or don't want to take a medicine because it makes them groggy, Cohen said. "So many of our admissions are precipitated by people not taking their medications," he said.

In the beginning

Few formally trained psychiatric nurses existed in the United States before the late 1800s, according to the American Psychiatric Nurses Association. Many opposed the idea of women caring for the insane. In 1882, Linda Richards, considered the first psychiatric nurse in the United States, opened Boston City Hospital Training School for Nurses to teach nurses to care for psychiatric patients. By the second decade of the 1900s, nursing schools had started to offer psychiatric nursing programs and eventually nursing programs at psychiatric hospitals closed. Graduate programs in psychiatric nursing began in the mid-1950s.

Until the 1960s, psychiatric patients were mostly cared for in state-run institutions, and nurses were trained to care for them there. At her orientation, Henley said, no one talked about intervention skills or evidence-based practice. Nurses did the housekeeping. No one worked with patients even on basic things like bowel and bladder control-they were changed when someone had a spare moment.

"As a new nurse, it was very frustrating for me," she said. "I was very unhappy with what I saw." She believes that many psychiatric nurses became strong advocates for the mentally ill because of what they experienced in those hospitals.