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When the patients left the institutions, so did the nurses. After state hospitals were ordered closed and patients released, community-based mental health centers staffed by nurses with advanced degrees were supposed to take over the care of the mentally ill.

The community mental health centers didn't work, said Jane White, DNSc, MSN, CS, RN, executive director of the American Psychiatric Nurses Association. The government never came through with funding for the centers, she said. "Those [community resources] fell apart." Instead, public funding for mental health plunged and has not come close to catching up. States spend fewer dollars on mental health now than they did in the '50s and '60s, Henley said.

Without community resources, "it's very difficult to rehabilitate patients," White said. Counties, which now bear the burden of mental health spending, don't have money to provide services. "We're there," White said of psychiatric nurses, "but we're there without resources, taking heavy caseloads."

A different direction

Although enrollment in advanced degree psychiatric nursing programs has dropped since the '60s and '70s, psychiatric nurses have a wide variety of jobs to choose from. Some are staff nurses in freestanding psychiatric hospitals or in the psychiatric units of general hospitals. Some work in home health, treating discharged mentally ill patients in their homes. Some work as psychoanalysts in private practice or as clinical nurse specialists in community mental health centers or hospitals.

Increasingly, many with advanced degrees are becoming psychiatric nurse practitioners, seeing patients and prescribing medication in private practice. Some specialize in treating children or adolescents; others may work in assisted living facilities with geriatric patients.

Smerko sees an important place for psychiatric nurse practitioners in long-term care, treating the elderly for mental as well as physical disorders. "You have to go in and take a good long and thorough look at what's going on," she said. For instance, delirium, depression and dementia may look the same in an older person, she said, but delirium, untreated, can result in death. Or an older person who seems depressed may be experiencing a side effect from a medication for a physical problem.

Smerko does a lot of consultation with family nurse practitioners who respect her knowledge of mental illness and the medications to treat it. "The relationship between the family adult nurse practitioners and the psychiatric nurse practitioner just keeps getting better all the time," she said.

As hospital stays for psychiatric patients have decreased, home health is playing a more important role in psychiatric care, said Dierdre Fisher, MSN, APRN, CNS, director of psychiatric services for Concord Home Care Inc. in San Antonio. Home health nurses have time to do more than just control symptoms, she said. "We get to see the families. We get to see the patients in their natural environment." Home health nurses can educate patients and families and help them stay out of the hospital, she said.

Besides deinstitutionalization, one of the greatest changes in psychiatric nursing has been the discovery of the role of neurotransmitters and the realization that most mental illnesses have a biological basis, psychiatric nurses say. As brain research has improved, so have the medicines that control mental illness.

"We have seen a great change from the old anti-psychotic drugs," Luna said. Those drugs had side effects such as weight gain and sluggishness that made patients not want to take them. The newer medications have fewer side effects or have ways to control the side effects and patients seem more willing to take them, nurses said.

The realization that mentally ill patients suffer from brain disorders has influenced not only the treatment of their symptoms, but the way they are treated by hospital staff, Saxe said. As with any medical patient, the nurse's greatest responsibility is to make the psychiatric patient feel safe and comfortable, she said, by talking, giving prescribed medications, adjusting the environment as much as possible and trying to control mental as well as physical pain.

"I personally believe that the No.1 thing that psychiatric nurses do is to use themselves as a therapeutic tool," Nadler-Moodie said. Psychiatric nurses don't have diagnostic tools such as X-rays or lab reports or even a reliable report from the patient to help figure out what is causing pain. They must rely on their ability to listen, talk and assess.

Many psychiatric patients who live on the streets or abuse substances are incapable of caring for themselves and have substantial physical as well as psychiatric problems. Luna recalled a patient who came into the emergency room claiming her vagina was falling out. The medical team thought she was hallucinating, but it turned out that she had a serious medical condition, and she was psychotic.