psychiatric mental health nursing

The Scope  Standards of Practice is currently in its third edition (2022). 

Psychiatric-Mental Health Nursing: Scope and Standards of Practice articulates the essentials of psychiatric-mental health nursing at multiple levels and settings. It reflects the diverse activities in which general and advanced practice psychiatric-mental health nurses are engaged and serves them in their clinical practice, education, research, and community service.

For more information and to order the third edition, . 

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© Copyright 2022  International Society of Psychiatric-Mental Health Nurses 2424 American Lane, Madison, WI 53704 | Phone:  608-443-2463 |  Fax:  608-333-0310 |  Email:   [email protected] ISPN Endorsement Policy            ISPN Privacy Policy            ISPN Social Media Policy

• Precepting at YSN
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Psychiatric-Mental Health

The psychiatric–mental health nurse practitioner (pmhnp) specialty prepares students for advanced practice in the provision of psychiatric–mental health services to individuals across the lifespan and their family members in a variety of settings., meet the faculty.

Join us on Tuesday, September 17, 2024 at 4 pm ET for a PMHNP Virtual Information Session. LEARN MORE

Students are prepared to care for individuals with psychiatric needs ranging from health promotion and risk reduction to complex and persistent mental illness.  Application of classic theories, research evidence, and a holistic bio-psycho-social-spiritual-cultural approach provides a comprehensive framework to developing knowledge and skills for clinical management. Courses and clinical experiences in the curriculum meet psychiatric-mental health population competencies required by the National Organization of Nurse Practitioner Faculties (NONPF). The PMHNP program meets the American Association of Colleges of Nursing’s (AACN) Essentials of Master’s Education in Nursing.  There is great need for PMHNP’s in the health care system and graduates typically are in demand as they enter the job market.

The Academic Experience

Yale School of Nursing attracts students nationally and internationally who have worked in a variety of fields and have unique backgrounds and experiences.  Students in the PMHNP program often have experience in clinical psychiatry and mental health settings which enriches their classroom experiences, offering a rich background and preparation for graduate study of the advanced practice psychiatric nursing role.  

Courses are offered on campus allowing for students to work closely together as a group and with faculty in learning to critically think about the complexity of caring for individuals with mental health needs and the advanced practice role in psychiatric-mental health nursing.  

The Program of Study

Courses include content in mental health assessment, neurobiology, psychopathology, developmental and personality theory, individual, group and family psychotherapy, and psychopharmacology. The PMHNP curriculum is embedded with core courses taken by all advanced practice nursing students at YSN including advanced health assessment, advanced pathophysiology, advanced pharmacology, health promotion, and evidence-based practice. Students can enter as a full time student in the Graduate Entry Pre-specialty in Nursing (GEPN) program or as an RN, where part time programs of study are also available.  

(Please see  Related Links  on the left for PDFs)

The Clinical Experience

Testimonals.

“Precepting students allows me to see patients through fresh, enthusiastic eyes. I love seeing patients I have been treating for 15+ years and having a student ask me a question about them I haven’t thought about recently. It instills new life and hope in my practice and my outlook on the nursing profession.” – Anonymous (AY 2019-2020)

Who Should Apply?

Prospective students must have demonstrated interest in the field of psychiatric-mental health nursing.  Successful candidates ideally have experience working in psychiatric settings or with individuals with mental health needs.  Having prior science course work is helpful for students, particularly to manage both the accelerated GEPN program and the concurrent core course work that is required in the PMHNP portion of the program. 

Certification & Licensure

Accreditation

Pmhnp faculty practice, pmhnp faculty.

Susan Boorin, PhD, APRN, PMHNP-BC

faculty who teach in the Psychiatric–Mental Health Nurse Practitioner Specialty

Katy Maggio,  MS, RN, ANP, PMHNP-BC

Lindsay Powell, DNP

Carissa Tufano, MSN, PMHNP-BC, APRN

Allison Underwood, MSN, PMHNP-BC

What Does a Psychiatric Nurse Practitioner Do?

• Psychiatric Nurse Practitioner Duties
• PMHNP Workplaces
• Day in the Life of a PMHNP
• Pros and Cons

A psychiatric mental health nurse practitioner (PMHNP) is a type of nurse practitioner who helps patients suffering from mental illnesses, disorders, or substance abuse problems by assessing, diagnosing, and providing treatment plans to them.

PMHNPs are in extremely high demand as the need for qualified mental health professionals is on the rise. According to the  National Alliance on Mental Illness (NAMI), 22.8% of U.S. adults experienced mental illness in 2021 (57.8 million people). Additionally, 7.6% of U.S. adults experienced a co-occurring substance use disorder and mental illness in 2021. 

This article will highlight some of the job responsibilities of a psychiatric nurse practitioner, including day-to-day duties, where you can work, and the pros and cons of the job. Keep reading to determine whether this career is right for you.

Popular Online Psychiatric-Mental Health Nurse Practitioner (PMHNP) Programs

WGU's award-winning online programs are created to help you succeed while graduating faster and with less debt. WGU is a CCNE accredited, nonprofit university offering nursing bachelor's and master's degrees.

Enrollment: Nationwide

• BSN-to-MSN - Psychiatric Mental Health NP

As a working RN, you need a flexible, transfer-friendly program to help you save time and money as you take the next step in your nursing career. In our CCNE-accredited4 RN to BSN program, you can transfer in up to 134 credits—which is nearly 75% of program requirements. Your transfer credits can be reviewed in one business day (on average).

Enrollment: FL

• MSN - Psychiatric-Mental Health NP
• See more Rasmussen nursing programs

At Ohio University, we provide aspiring and current nursing professionals programs and credentials that will help them launch their careers and advance toward leadership positions. 

Enrollment: Nationwide, except AL, AZ, CO, DE, GA, IA, ID, KS, LA, MD, ND, NE, NY, OK, OR, RI, SD, TN, UT, VA, WA, and WY

• Post-Grad Certificate - Psychiatric Mental Health NP

The R.N. to M.S.N program is for registered nurses with associate degrees who want to become nurse practitioners. It focuses on advanced clinical skills, professionalism and evidence-based practice. Our integrated exam preparation courses provide dedicated study resources, leading to impressive passing rates consistently above the national average and graduate success.

• MSN - Psychiatric Mental Health NP
• RN-to-MSN - Psychiatric Mental Health NP

Earn an M.S. in Nursing online at the Wegmans School of Nursing, ranked among the top 100 nursing schools nationwide. Bachelor’s in nursing and RN license required. The online pathway from NY’s No. 6-ranked nursing school combines live classes, 600 hours of clinical rotations, and on-campus immersions to prepare you to pursue NP licensure

Enrollment: NY only

• Psychiatric Mental Health NP (PMHNP)

The specific duties of a psychiatric nurse practitioner will vary depending on location and patient population. Additionally, PMHNPs can be limited in their practice depending on the state of practice.

Here is an overview of what PMHNPs do:

Patient Care 

PMHNPs are responsible for overseeing the care of patients with a variety of mental illnesses and disorders, including, 

• Bipolar disorder
• Eating disorders
• Trauma-related disorders
• Smoking cessation
• Obsessive-Compulsive Disorder
• Schizophrenia
• Panic Disorders
• Disruptive behavior

Caring for patients with these illnesses and disorders requires individualized treatment plans and will vary depending on the patient. Generally, these patients benefit from both medication and non-medication treatment plans.

Specifically, PMHNPs will be responsible for the following, 

• Diagnosing and treating common acute psychiatric problems, illnesses, and crises
• Psychopharmacologic management in collaboration with a psychiatrist
• Providing individual, group, and family psychotherapy
• Caring for and counseling clients with commonly identified chronic psychiatric conditions
• Coordinating and integrating multidisciplinary services for clients with complex psychiatric problems
• Monitoring common healthcare problems and referring to specialized medical treatment as needed
• Performing or recommending age-appropriate screening procedures
• Emergency psychiatric care

From educating about medications to running group therapy sessions, a PMHNP is responsible for caring for the entire patient. Oftentimes, patients with mental health disorders and illnesses will receive complementary therapies with their pharmacological regimens. 

PMHNPs will educate patients as well as their support systems with information regarding illness, treatment plans, and medications. 

>> Show Me Online Psychiatric Nurse Practitioner Programs

Where Do Psychiatric Mental Health Nurse Practitioners Work?

Psychiatric nurse practitioners are becoming increasingly popular as mental health illnesses are on the rise. This makes becoming a PMHNP a very desirable career option, with the ability to work in a variety of locations. Those locations include, 

• In-patient Psychiatric Facilities
• Primary Healthcare Clinics
• Private Psychiatric Practices
• Psychopharmacology Clinic
• Psychiatric Consult Services
• Public health agencies
• Residential Substance Abuse Facilities
• State Psychiatric Facilities
• Student Health Clinics
• Urban Nurse-Managed Clinic
• Veterans Administration Psychiatric Facilities

A Day in the Life of a Psychiatric Nurse Practitioner

Shifts as a PMHNP will follow a similar pattern, as it is important for patients with mental illness and disorder to have structure. So, the schedule of a PMHNP will follow a similar suit. However, this does depend on the location. PMHNPs who work in a hospital or psychiatric facility will have very similar days.

>> Related:  Psychiatric Nurse Practitioner vs Psychiatrist Differences

1. Receiving a Sign-Out From the Overnight Team

You can expect to start your day by receiving a sign-out from the overnight team on the patients and any changes that may have occurred over the previous shift. 

2. Make the Rounds

The PMHNP will join the rest of the medical team for rounds on the patients. The team will vary but may consist of a psychiatrist, psychologist, social worker, and case manager. 

3. Visit Patients 

After morning rounds, most PMHNPs will physically go and see their patients as well as update them on plans for the day. 

Depending on the type and severity of mental health illness, the patients might be seen in a common room or in their own room. They will also discuss progress in their treatment plans and any news of discharge of facility placements. 

4. Place Orders

Once morning rounds are all complete, orders are placed to reflect the change in the plan of care for the day. 

5. Tend to Patients

PMHNPs will continue to tend to their patients throughout their shifts, making any necessary changes to their medication regimen. In fact, PMHNPs, while specializing in mental health disorders, are also generally responsible for the overall health and well-being of their patients. 

Pros and Cons of Being a Psychiatric Nurse Practitioner

Being a PMHNP can be a rewarding career, especially in helping those who are struggling in their everyday lives. However, it can also be frustrating as mental health and illness are ongoing and often uphill battles for many patients. In fact, many patients’ mental illnesses are often compounded by substance abuse, making the job of a PMHNP even more difficult.

>> Related: Shortest Online PMHNP Certificate Programs

• Work in a high-demand career
• Job security
• Help others
• Competitive salary
• Flexibility 
• Individualized care of patients
• Telehealth opportunities
• Advocate for patients
• Reduce the stigma associated with mental health disorders
• Work in nontraditional settings
• Emotional stress
• Can be dangerous depending on the work environment
• High-stress environments
• Ethical dilemmas
• Legal responsibilities 
• High chance of burnout

Next Steps to Becoming a PMHNP

Becoming a PMHNP is a fulfilling career, especially for those who are willing to put in the time and effort to make a lasting difference in their patients’ lives. 

There are many reasons to become a PMHNP, but it’s important to remember that mental health is not always as easy to diagnose and fix as other diseases. To take the next step in your career, check out our comprehensive PMHNP resources:

• How to Become a Psychiatric Nurse Practitioner (PMHNP)
• Top Psychiatric Nurse Practitioner Programs
• 10 Cheapest Online PMHNP Certificate Programs
• Top One-Year Online PMHNP Programs

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Psychiatric-Mental Health Nursing Certification (PMH-BC ™ )

Credential awarded: pmh-bc™.

The ANCC Psychiatric–Mental Health Nursing board certification examination is a competency based examination that provides a valid and reliable assessment of the entry-level clinical knowledge and skills of registered nurses in the psychiatric–mental health specialty after initial RN licensure. Once you complete eligibility requirements to take the certification examination and successfully pass the exam, you are awarded the credential: Psychiatric Mental Health Nurse – Board Certified (PMH-BC™). This credential is valid for 5 years.

Effective September 16, 2024: The Test Content Outline and Reference List for the Psychiatric-Mental Health Nursing certification exam will be updated. Please access the appropriate Test Content Outlines and Reference Lists below. There will be a 6-business day test suspension period to allow for the exams to be updated. You may test before September 6, 2024, or after September 15, 2024.

The Accreditation Board for Specialty Nursing Certification (ABSNC) accredits this ANCC certification.

NOTICE: We are currently experiencing issues with new certification and renewal processes. We apologize for any inconvenience this has caused you.

Download the offline application form         Download the offline renewal form

Apply online         Renew online

See below for instruction and pricing for new and renewal applications.

Apply for Certification

Initial certification application.

You may apply for this computer-based test year round and test during a 120-day window at a time and location convenient to you. The exam allows 3 hours to answer 150 questions (125 scored plus 25 pretest questions that are not scored). For exam prep resources, scroll down to view Study Aids. If you do not pass a certification exam, learn about retesting .

STEP 1: Review Pricing, Eligibility Requirements, and FAQs

Review certification pricing and eligibility requirements below. FAQs provide a deeper dive into topics including online application, document submission, APRN and RN specialty certification requirements, and renewal requirements.

REVIEW FAQs

See Pricing & Discounts

Eligibility

• Hold a current, active RN license in a state or territory of the United States or hold the professional, legally recognized equivalent in another country
• Have practiced the equivalent of 2 years full-time as a registered nurse
• Have a minimum of 2,000 hours of clinical practice in psychiatric–mental health nursing within the last 3 years
• Have completed 30 hours of continuing education in psychiatric–mental health nursing within the last 3 years

Apply from Outside the U.S.

Learn about additional requirements for candidates outside the U.S.

STEP 2:  Apply

APPLY ONLINE

Step 3: Testing

To schedule your exam, visit the Prometric website at https://www.prometric.com/ancc and use your certification number to schedule your exam

Maintain & Renew

Maintain certification.

To maintain certification, complete professional development requirements between the start and end dates of your certification, and provide this information on your renewal application.

CALENDAR Your Renewal Date

Certifications are renewed every 5 years. You may submit a renewal application up to 1 year prior to your expiration. You may be ineligible to practice beyond your expiration date.

CREATE an ANCC Account

Track professional development, mail preferences and purchases in one place. Online applications are also stored in your account. Visit Access My Account

UPDATE Contact Information

If you move, change names or acquire a new phone or email, please update contact details in your account. Or email Customer Care or call 1.800.284.2378.

DISPLAY Your Credentials

Learn common questions and answers about displaying your credentials in the proper order. Download How to Display Your Credentials .

TRACK PROFESSIONAL DEVELOPMENT WITH ANCC

Online renewal is simpler when you store professional development activities in your ANCC account immediately upon completion. At renewal, you can transfer stored information to the renewal application, saving time. Note: To renew online, you must store professional development activities before starting the online renewal application.

• After each activity, gather proof of professional development.
• Click Track Professional Development to the right.
• Enter and save professional development activities.
• From account summary, top right column, under Professional Development find links to enter continuing education (contact hours), academic credits, presentations, publications/research, preceptorship and professional service.

Renew Certification

Renewal certification application.

You may submit a renewal application up to 1 year prior to your expiration.

STEP 1: Review Requirements, FAQs, and Pricing

Download renewal requirements     Read renewal FAQs

*Separate membership discounts apply.

• Prices above include $140 non-refundable administrative fee. Additional fees for special services may apply. See application for details.
• Discounts may be claimed for up to 5 business days after ANCC receives your application. Discount claims received after this time will not be honored and refunds will not be issued.

STEP 2: Submit Renewal Application

Required: BEFORE starting a renewal application online, proof of professional development must be entered and stored in your ANCC online account. To record professional development activities go to Track Professional Development with ANCC. Then return to renew online.

RENEW ONLINE     TRACK PROFESSIONAL DEVELOPMENT

RENEW BY MAIL

If you would like to renew by mail, please send a request to [email protected] .

Download  General testing & renewal handbook [pdf]

Email us , or call 1.800.284.2378

ANCC Retired Certified Nurse Recognition celebrates achievements for life!

ANCC Study Aids

• Test Content Outline For Exams On or Before September 5, 2024 pdf (0.52MB)
• Test Content Outline For Exams On or After September 16, 2024 pdf (0.55MB)
• Test Reference List For Exams On or Before September 5, 2024 pdf (0.12MB)
• Test Reference List For Exams On or After September 16, 2024 pdf (0.21MB)
• Psychiatric-Mental Health Nursing Readiness Test
• Sample Test Questions & Answers
• Role Delineation Study For Exams On or Before September 5, 2024 pdf (0.23MB)
• Role Delineation Study For Exams On or After September 16, 2024 pdf (0.21MB)
• Prometric Test Centers
• General Testing and Renewal Handbook [pdf] pdf (0.53MB)
• Certification Seven Tips pdf (0.90MB)
• Exam Scores & Retesting
• How to Display Your Credentials pdf (0.09MB)

You might also like

Psychiatric-Mental Health Nursing Review and Resource Manual 5th Edition with 2020 Addendum

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Psychiatric/Mental Health Nurse

What is a psychiatric/mental health nurse psychiatric/mental health nurses specialize in the care of patients with mental illnesses or mental distress. they provide comprehensive care, which includes assessing mental health needs, developing nursing plans, administering psychiatric medication, and offering therapy and counseling. these nurses work closely with patients to manage their conditions and improve their mental health. they work in a variety of settings, such as psychiatric hospitals, mental health clinics, community health centers, and private practices. their role is vital in providing both acute and long-term care for patients with mental health disorders. these nurses play an instrumental role in educating patients and their families about mental health, developing strategies for coping with mental illness, and advocating for the rights of people with mental health issues. to advance in the field, psychiatric/mental health nurses often pursue additional training and certifications, such as becoming a psychiatric-mental health nurse practitioner (pmhnp). the role of a psychiatric/mental health nurse is becoming increasingly critical in the healthcare sector, with a growing recognition of their importance in addressing widespread mental health issues. { "@context": "https://schema.org", "@type": "faqpage", "mainentity": [{ "@type": "question", "name": "what is a psychiatric/mental health nurse", "acceptedanswer": { "@type": "answer", "text": "psychiatric/mental health nurses specialize in the care of patients with mental illnesses or mental distress. they provide comprehensive care, which includes assessing mental health needs, developing nursing plans, administering psychiatric medication, and offering therapy and counseling. these nurses work closely with patients to manage their conditions and improve their mental health." } },{ "@type": "question", "name": "what does a psychiatric/mental health nurse do", "acceptedanswer": { "@type": "answer", "text": "psychiatric/mental health nurses perform various duties, including: conducting mental health assessments developing and implementing treatment plans administering psychiatric medications and monitoring their effects providing therapy and counseling to patients offering support and education to patients' families advocating for patients' mental health needs and rights coordinating care with psychiatrists, psychologists, and other healthcare professionals " } },{ "@type": "question", "name": "what skills does a psychiatric/mental health nurse need", "acceptedanswer": { "@type": "answer", "text": " profound knowledge of psychiatric disorders and treatments empathy and understanding towards patients with mental health issues strong communication skills for effective patient interaction ability to manage crises and challenging behaviors patience and resilience in a demanding work environment skills in therapeutic communication and counseling " } }] } what does a psychiatric/mental health nurse do psychiatric/mental health nurses perform various duties, including: conducting mental health assessments developing and implementing treatment plans administering psychiatric medications and monitoring their effects providing therapy and counseling to patients offering support and education to patients' families advocating for patients' mental health needs and rights coordinating care with psychiatrists, psychologists, and other healthcare professionals what skills does a psychiatric/mental health nurse need.

Key skills for Psychiatric/Mental Health Nurses include:

• Profound knowledge of psychiatric disorders and treatments
• Empathy and understanding towards patients with mental health issues
• Strong communication skills for effective patient interaction
• Ability to manage crises and challenging behaviors
• Patience and resilience in a demanding work environment
• Skills in therapeutic communication and counseling

What skills does a Psychiatric/Mental Health Nurse need? Key skills for Psychiatric/Mental Health Nurses include: Profound knowledge of psychiatric disorders and treatments Empathy and understanding towards patients with mental health issues Strong communication skills for effective patient interaction Ability to manage crises and challenging behaviors Patience and resilience in a demanding work environment Skills in therapeutic communication and counseling Learn More About Psychiatric/Mental Health Nurses Work settings for Psychiatric/Mental Health Nurses Psychiatric/Mental Health Nurses work in: Psychiatric and mental health hospitals General hospitals with psychiatric units Outpatient mental health clinics Community health centers Residential mental health facilities Private practice settings Common Cases Psychiatric/Mental Health Nurses Encounter Mood disorders, such as depression and bipolar disorder Anxiety disorders, including panic disorder and OCD Psychotic disorders like schizophrenia Substance abuse and addiction disorders Personality and eating disorders Trauma and stress-related disorders How to Become A Psychiatric/Mental Health Nurse Complete an ADN or BSN degree in nursing. Pass the NCLEX-RN exam to obtain RN licensure. Gain experience in psychiatric nursing or mental health settings. Achieve a certification in mental health nursing .  Alternatively, become an Advanced Practice Registered Nurse (APRN) or a Nurse Practitioner (NP), with a concentration in mental health care. How to Advance Your Career As A Psychiatric/Mental Health Nurse Advancement opportunities include: Earning a Master’s or Doctoral degree in Psychiatric-Mental Health Nursing. Becoming a Psychiatric Nurse Practitioner or Clinical Nurse Specialist. Engaging in research or academic roles within the field of mental health. Leading or managing psychiatric nursing teams or departments. Education Requirements & Helpful Certification Board Certification in Psychiatric-Mental Health Nursing (PMH-BC) from the American Nurses Credentialing Center (ANCC). Ongoing education in psychiatric and mental health care practices. Average Salary For Psychiatric/Mental Health Nurses According to Salary.com, as of 2023, the average salary for a Psychiatric Nurse in the United States ranges from $69,745 to $103,942, with the median salary being around $83,500​​.  These figures can vary based on several factors including geographic location, years of experience, education level, and specific employer. Specialty Organizations & Communities American Psychiatric Nurses Association (APNA) International Society of Psychiatric-Mental Health Nurses (ISPN) Ideal Personality Traits Browse Jobs Let's start building the life you want.

Education Requirements

• Board Certification in Psychiatric-Mental Health Nursing (PMH-BC) from the American Nurses Credentialing Center (ANCC).
• Ongoing education in psychiatric and mental health care practices.

How to advance/career pathway

Advancement opportunities include:

• Earning a Master’s or Doctoral degree in Psychiatric-Mental Health Nursing.
• Becoming a Psychiatric Nurse Practitioner or Clinical Nurse Specialist.
• Engaging in research or academic roles within the field of mental health.
• Leading or managing psychiatric nursing teams or departments.

RESPONSIBILITIES

Most common cases.

• Mood disorders, such as depression and bipolar disorder
• Anxiety disorders, including panic disorder and OCD
• Psychotic disorders like schizophrenia
• Substance abuse and addiction disorders
• Personality and eating disorders
• Trauma and stress-related disorders

How to become a

• Complete an ADN or BSN degree in nursing.
• Pass the NCLEX-RN exam to obtain RN licensure.
• Gain experience in psychiatric nursing or mental health settings.
• Achieve a certification in mental health nursing . 
• Alternatively, become an Advanced Practice Registered Nurse (APRN) or a Nurse Practitioner (NP), with a concentration in mental health care.

Specialty Groups and Communities

• American Psychiatric Nurses Association (APNA)
• International Society of Psychiatric-Mental Health Nurses (ISPN)

Personality Traits

Average salary.

According to Salary.com, as of 2023, the average salary for a Psychiatric Nurse in the United States ranges from $69,745 to $103,942, with the median salary being around $83,500​​. 

These figures can vary based on several factors including geographic location, years of experience, education level, and specific employer.

Certifications

Work setting.

Psychiatric/Mental Health Nurses work in:

• Psychiatric and mental health hospitals
• General hospitals with psychiatric units
• Outpatient mental health clinics
• Community health centers
• Residential mental health facilities
• Private practice settings

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The role of psychiatric mental health nurse practitioners in improving mental and behavioral health care delivery for children and adolescents in multiple settings

Aparna kumar.

Thomas Jefferson University, Children’s Hospital of Philadelphia

Anne Kearney

Children’s Hospital of Philadelphia

Katelin Hoskins

University of Pennsylvania, School of Nursing, Children’s Hospital of Philadelphia

Anita Iyengar

University of Pennsylvania, School of Nursing

Introduction

In 2011 the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) released their landmark report, Future of Nursing 2020 , calling for nurses to serve as “full partners” in shaping the future of the healthcare system and laying out a series of goals for the profession to obtain by the year 2020 ( Institute of Medicine [IOM], 2011 ). In a time of rising rates of childhood mental health disorders ( O’Connell, Boat, & Warner, 2009 ), including an increase in youth suicide ( Hedegaard, Curtin, & Warner, 2018 ), the need for strong nursing leadership and innovation in healthcare is not only a professional obligation, but a moral one. In this paper, we reflect on the ways that psychiatric-mental health nursing has yet to achieve the Future of Nursing 2020 goals as they apply to child and adolescent mental health, and offer a starting point for conversation about what goals need to be set for the decade ahead. Namely, we focus on recommendation 1 (remove scope of practice barriers), recommendation 2 (expanding opportunities for nurses to lead and diffuse collaborative improvement efforts), recommendation 3 (implement nurse residency programs), recommendation 7 (prepare and enable nurses to lead change to advance health), and recommendation 8 (build an infrastructure for the collection and analysis of inter-professional health care workforce data). We propose that Psychiatric-Mental Health Nurse Practitioners (PMHNPs) in particular should play a more active role in increasing access to more “advanced” level mental health care in pediatric primary care, and should align their professional, educational, and legislative goals towards that end.

Background and Significance

The troubling state of mental health among youth in the United States demands attention. Recent data estimates that between 13–20% of children in the United States have been diagnosed with a mental, emotional, or behavioral disorder ( Perou, et al., 2013 ). Over the past two decades, it has also become clear that mental health disorders are on the rise among children and adolescents ( O’Connell, Boat, & Warner, 2009 ), and suicide is now the second leading cause of death for people from the ages of 10 to 34 ( Hedegaard, Curtin, & Warner, 2018 ). Furthermore, emergency room visits for non-fatal self-inflicted injuries among adolescents has also increased, highlighting the increasing acuity of mental health concerns in the U.S. ( Mercado et al., 2017 ).

The most basic definition of childhood mental health is “the achievement of development and emotional milestones, healthy social development, and effective coping skills, such that mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities” ( Perou, et al. 2013 , p. 2). When mental, emotional, and behavioral health disorders are not effectively treated, the impact on the individual, their families, and society more broadly can be devastating and long-lasting. The cost of mental disorders in youth under the age of 24 years is approximately $247 billion annually, positioning them among the most costly health conditions in childhood ( Perou et al., 2013 ).

The World Health Organization (WHO) estimates that 50% of mental health disorders start before the age of 14 ( WHO, 2013 ). Despite the prevalence and the serious functional impact of these disorders, they remain undertreated and underdiagnosed. Approximately only half of all children with a diagnosed mental, emotional, or behavioral health condition receive formal treatment from a mental health care provider each year ( Child and Adolescent Health Measurement Initiative, 2017 ), which does not account for the myriad children and adolescents who go undiagnosed and untreated. Appropriate diagnosis itself is predicated upon access to care, a significant structural barrier in our current health care delivery system ( Cummings, Wen & Druss, 2013 ).

Given the high prevalence of mental health disorders, significant impact, and unmet treatment needs, Psychiatric-Mental Health Nurse Practitioners (PMHNPs) have the opportunity, as well as the ethical and professional obligation, to play a leading role in improving child and adolescent mental health. As we will discuss later in this commentary, we face a shortage of mental health providers. The health care system’s tendency to conceptualize advanced practice nurses as generalist “physician extenders” obfuscates the nursing model upon which advanced practice nurses (APNs) are trained and misrepresents APN scope of practice. Furthermore, predicating service delivery on medical models of care, which are traditionally disease- and illness-oriented, may compound structural limitations if social determinants remain unaddressed ( American Association of Nurse Practitioners, 2015 ). The current mental health care delivery model – shaped by reimbursement demands and limited evidence-based interventions – is suboptimal for serving patients and families. ( Kaye et al., 2009 ). Rather, the PMHNP role should not model that of traditional psychiatry. Instead, starting from the nursing framework, we must align with patient needs to design future systems and to position ourselves as providers of a distinct domain of mental health care, delivering what can be thought of us “primary mental health care”; that is, care based on the general mental health needs of the population.

Nearly 10 years after the landmark Future of Nursing report ( IOM, 2011 ) and as the profession prepares for the release of the Robert Wood Johnson/National Academy of Medicine Future of Nursing 2020–2030 report, now is the time to consider the future of psychiatric-mental health nursing and the ways in which nurses can work to improve the delivery of mental health care for children and adolescents. This paper seeks to explore the current landscape of mental health care, how the nursing framework and current theoretical knowledge can broaden and expand the role of the PMHNP, and ultimately what resources may be needed to push forward lasting and dramatic change in the way we practice. It also aims to address the IOM recommendations as they apply to psychiatric mental health nurse practitioners in this current landscape of care.

Current State of the Future of Nursing Recommendations

Experts have described the arena of children’s mental health as a “labyrinth of systems” ( Miles, Espiritu, Horen, Sebian, & Waetzig, 2010 ), reflecting its complex nature and characterized as multiple silos of influence where children receive care. These silos include public health systems, schools, communities, faith organizations, primary care and even informal care. In the last decade, there have been increasing calls to integrate mental, emotional, and behavioral wellness care into the provision of general health care of children, but significant barriers remain. Perhaps the most salient barrier is the lack of qualified, specialized mental health providers. However, while primary care providers can and should provide treatment for mental health disorders in childhood, the nature of mental health diagnosis and treatment, especially in children, means that patients are often most appropriately served by professionals with specific graduate-level preparation and board-level certification in psychiatric care. It should be noted that the Pediatric Nursing Certification Board (PNCB) offers a Pediatric Primary Care Mental Health Specialist Exam (PMHS) for Pediatric Nurse Practitioners (PNP). This is an addition to certification to validate knowledge of “primary care” level intervention, consistent with the Licensure Accreditation Certification and Education (LACE) model. It is not a certification that expands the scope of a Pediatric Nurse Practitioner’s practice (Pediatric Nursing Certification Board, n.d.).

At the most basic level, primary care delivery in the United States is not optimally designed to support the effective delivery of mental health interventions due to challenges in coordination of universal screening of mental health conditions, lack of compensation for screening and treatment, limited availability for follow up, and lack of resources for referral ( Wissow, et al, 2013 ). Expanding the reach of current and future mental health care providers, namely PMHNPs, is therefore of the utmost importance.

Role of the Psychiatric-Mental Health Nurse Practitioner (PMHNP)

Relevance to iom recommendations.

Recommendation 1 of the IOM Future of Nursing report notes that it is imperative to remove scope of practice barriers in order for providers to practice to the full extent of their education and training ( IOM, 2011 ). The current role of the PMHNPs that treat children and adolescents is limited by current regulatory standards as well as state specific requirements for physician collaboration, resulting in an incomplete role in communities and systems. Recommendation 2 also applies to the role and scope as we envision and propose a role in which the PMHNP can lead and manage collaborations with providers, systems, and services ( IOM, 2011 ).

Current Definition of the PMHNP Role

The PMHNP role has the theoretical orientation, education, and scope to be an effective provider of child and adolescent mental health services. The American Psychiatric Nurses Association (APNA) takes the policy position that psychiatric nurses should be considered members of the primary care workforce; this is in contrast to the traditional medical model, which positions mental health care as a specialty discipline. The responsibilities of the PMHNP role are founded on the nursing process and therapeutic relationship and include: educating patients and families; diagnosing, treating, and managing acute illness; providing psychotherapy; prescribing medication for acute and chronic illness; diagnosing, treating, and managing acute illness; providing care coordination; making referrals; ordering, performing, and interpreting lab tests, diagnostic studies; and providing preventative care including screening ( APNA, 2019 ). In the current delivery system, PMHNPs deliver consultative psychiatric services to primary care settings. These services can take the form of telephonic or video consultation, education for providers, resource coordination, collaboration with providers, and in person or virtual consultation ( Kalieb, 2017 ). However, in both the general preventive as well as a consultative role of the PMHNP, there is potential to expand beyond these services to include basic interventions such as sleep hygiene, healthy nutrition, parental support, increasing quality of parent-child interaction, and relaxation and coping strategies. Simple and brief intervention as well as cognitive behavioral therapy (CBT) strategies may also be integrated into the role. Such competencies should be more explicitly defined as part of the PMHNP role.

While the skillsets of psychotherapy or medication management may overlap with colleagues from other disciplines (e.g., psychiatry, social work, psychology), all PMHNPs are registered nurses and the nursing framework is central to their role ( APNA, 2019 ). Using a nursing framework to conceptualize childhood mental health care should be at the core of the skill set of the PMHNP. Collaboration and partnership; care in the community informed by the community; a focus on education, health promotion and screening; and ultimately a model focused on wellness and recovery versus cure would characterize a nursing-driven, bottom-up child mental health paradigm. By using the nursing framework, even within current legislative constraints, PMHNPs can better address the IOM’s recommendation to practice to the full extent of scope ( IOM, 2011 ).

Collaboration and Partnership

Nurses are educated, trained, and practice in multidisciplinary venues. Key to the nursing role is the ability to utilize and capitalize on collaboration with other disciplines, in the traditional health sphere and outside of it. Mental health practitioners, to a greater extent than many health care practitioners, must effectively work with professionals in other disciplines, like neurology, endocrinology, nutrition, education, social work, psychology, and the justice system. An orientation towards partnership and collaboration should be seen as a strength. The nature of this collaborative ethos fits with the World Health Organization’s (WHO) call to action. The WHO stated that “greater collaboration with ‘informal’ mental health care providers, including families, as well as religious leaders, faith healers, traditional healers, school teachers, police officers and local nongovernmental organizations, is also needed” ( WHO, 2013 , p. 14).

Community Based Care

Nurses often provide care within communities. Visiting nurse services, nurse-family partnership initiatives, home care nursing, school nursing, and correctional nursing are just a few of the areas where nurses already practice in non-traditional clinical settings. As children most frequently receive mental health care in non-traditional clinical settings such as schools, community organizations, religious institutions, emergency departments, and the juvenile justice system ( O’Connell, Boat, & Warner, 2009 ), the field of psychiatric mental health nursing has the opportunity to capitalize on its history, experience, and knowledge of delivering community-based care. Since the mid-1990s, research has suggested that schools are a de facto mental health care system where both children with and without a mental health diagnosis receive services ( Burns et al., 1995 ). Hence, school nursing, in particular, offers opportunities for increasing access to care for children and adolescents. Beyond increasing access to care, working in the community helps nurses provide care informed by the strengths and challenges unique to the community. For example, a common recommendation given in mental health is to increase exercise by “going for a walk outside;” The responsibility of the nurse is to recognize that not every patient lives in a safe neighborhood and to adapt the recommendation appropriately.

Nurses are also able to holistically screen for, manage, and coordinate care. The WHO (2013) states that “health workers must not limit intervention to improving mental health but also attend to the physical health care needs of children, adolescents and adults with mental disorders, and vice versa, because of the high rates of comorbid physical and mental health problems and associated risk factors, for example, high rates of tobacco consumption, that go unaddressed (p. 14)”. Attendance to both physical and mental care may be implemented at the individual, system, or structural level. For example, facilitated referral models offer quick referral when physical health concerns are screened; co-located models offer both mental and physical health services in the same physical setting; and in-house models offer an integrated evaluation of physical and mental health needs ( Substance Use and Mental Health Services Administration [SAMHSA], 2013 ). The defined role of the PMHNP is especially amenable to the core competencies of integrated care including: family and youth focus with coordination, individualized and coordinated care plans, use of evidence-based guidelines, established relationships with other entities, and data informed planning ( SAMHSA, 2013 ). At the provider level the themes of coordination and individualized planning is akin to the nursing model.

The PMHNP should be an active member of the care team as noted in recommendation 2, continuously working to improve inefficient and harmful systems of care and as full partners in the design of health care in the United States ( IOM, 2011 ). This recommendation implies that nurses not only work with physicians and other health care professionals, but that they also actively provide input and implement change in their sphere of professional influence. This recommendation is especially important to the area of child and adolescent mental health given the IOM’s current calls for reform. In 2019, Skokauskas et al. outlined a vision for the future of child and adolescent psychiatry based on international consensus. Key goals involved increasing the workforce, reorienting child and adolescent mental health services with a public health orientation, increasing research and research training, and increasing advocacy. Restructuring the role of all mental health providers so that psychiatrists primarily focus on diagnostic evaluation, assessment and treatment of complex cases, as well as collaboration with other professionals providing mental health care is a central component of their vision ( Skokauskas et al., 2019 ). This recommendation suggests the inherent value of PMHNPs’ expertise. PMHNP practice includes the integration of multidisciplinary knowledge and the provision of holistic care. It is a starting point from which to envision the future potential role.

Child and Adolescent Mental Health Workforce

Relevance to iom recommendation.

Workforce demands are highly relevant to the IOM’s recommendation 8 to build more sophisticated structures for gathering inter-professional data ( IOM, 2011 ). This directly relates to the current knowledge about PMHNPs as a member of the psychiatric mental health workforce, specifically as it relates to child and adolescent providers.

Current Workforce Estimates

National estimates are that the demand for mental health workers will exceed supply by 250,000 by 2025 with 96% of all counties in the United States facing a shortage of mental health prescribers ( APNA, 2019 ). PMHNPs are considered to be a critical component of the mental health workforce, yet represent the smallest proportion of providers. At the same time, they are among only few groups of providers with prescriptive authority ( Heisler & Bagalman, 2013 ). No state in the United States has enough prescribers, and 43 states have a severe shortage ( Tyler, Hulkower, & Kaminski, 2017 ). In addition, several sources note that there is a risk of supply not meeting demand in the projected mental health workforce over the next 20 years ( HRSA, 2016 ; Beck, Page, Buche, Rittman, & Gaiser, 2018 ; Chattopadhyay, Zangaro, & White, 2015 ). According to the Health Resources and Service Administration (HRSA), supply will exceed demand for psychiatrists, but not PMHNPs, by 2030 ( HRSA, 2016 ). This is based on estimations assuming that PMHNPs and psychiatrists provide inherently different services, with psychiatrists performing the bulk of prescribing medications. In a 2018 survey of the psychiatric mental health workforce, PMHNPs comprised approximately 26.3% (n=17,534), psychiatrists 70.5% (n=47,046), psychiatric physician assistants 1.7% (n=1,164), and psychiatric pharmacists 1.5% (n=996) of the workforce ( Beck et al., 2018 ). HRSA notes that there are 7,670 nurse practitioners practicing in psychiatry ( HRSA, 2016 ) and nurse practitioner workforce estimates in 2008 and 2012 approximate that there are 7,500 nurse practitioners in psychiatry ( Chattopadhyay, Zangaro, & White, 2015 ); this discrepancy is likely related to the inclusion of clinical nurse specialists in the Beck et al. study (2018) . Geographically, PMHNPs are concentrated in the Northeastern United States as well as the Pacific Northwest and Alaska ( Beck et al., 2018 ), reflecting preference for location based on scope of practice and likely collaborator or supervisor availability if needed. Interestingly, while physician training programs tend to retain students in their states, PMHNP programs do not, suggesting an overall wider geographic distribution of graduates and further potential for expanding the workforce in shortage areas ( Beck et al., 2018 ).

Despite this data on the overall PMHNP workforce, little data exists specifically tracking PMHNPs who provide services for children and adolescents. One study identified that interest in filling the gap in child and adolescent psychiatrists with PMHNPs has been present for at least a decade; however required collaborative or supervisory agreements, high PHMNP salary expectations, and PMHNP prescribing comfort are seen as barriers to expansion of services ( Kaye et al., 2009 ). Additional data is needed to understand how shifting models of care may disproportionately shift care to PMHNPs. Based on current models, health services researchers anticipate that supply will meet demand by 2030, however this assumes that PMHNP geographical distribution is adequate, that other members of the workforce will need to increase to meet demand (such as child and adolescent psychiatrists), and that PMHNPs are practicing in roles of care that will remain stable over time ( National Center for Health Workforce Data, 2018 ). Further data is needed, highlighting recommendation 8 for greater data on the child and adolescent PMHNP workforce.

Shifting Landscape and Theoretical Framework

Given the current workforce, PMHNPs must continue to actively develop and shape their skillset and to aim to fill in the gaps in mental health care. Despite data that may suggest that the current workforce will meet demands, when examined in light of the gaps for child and adolescent psychiatrists, it is likely that there will be unmet need. Before discussing the potential role and scope of the PMHNP, we must critically reflect on the biopsychosocial model, which often informs care and treatment. In the biopsychosocial model three spheres of influence – biological factors such as genes, psychological factors such as stress, and social factors such as culture – interplay to impact health status ( Borrell-Carrio, Suchman, & Epstein, 2004 ). The model was proposed to counter the dehumanization of the patient by medical care. It posited three central concepts: 1) body and mind could not be seen separately; 2) a whole human could not be segmented into smaller unrelated parts; and 3) an observer undoubtedly influenced observation ( Borrell-Carrio, Suchman, & Epstein, 2004 ). While a useful framework, using a public health approach to guide the expanded role of the PMHNP can complement and expand the biopsychosocial model beyond individual aspects of treatment, as well as to re-imagine the PMHNP role. Given limitations in the child and adolescent mental health workforce, reshaping this role will allow for the greatest expansion of services.

A public health model for the child and adolescent PMHNP focuses on the population and improving its overall welfare (Stiffman et al., 2011). Adopting a public health approach of health promotion, prevention, and treatment aligns directly with nursing goals of holistic, person-centered care. The classic pyramid of a public health model starts with health promotion and optimization of mental health activities for all children and adolescents on the bottom (primary prevention), prevention activities targeted at children and adolescents with emerging symptoms in the middle portion (secondary prevention), and focused and individual based treatment on the top of the pyramid (tertiary prevention). Tertiary care may be defined as care provided by psychiatrists as well as PMHNPs for those experiencing acute onset of symptoms or symptom recurrence/relapse. This model parallels the proportion of children and adolescents served in each stage. The PMHNP can be engaged at every step and in fact integrate the care of each step rather than reducing the role to acute care for those experiencing acute onset of illness. While the role and function of the PMHNP may continue to involve medication management and therapy, taking a broader view of the treatment model can allow one to envision the role across various settings. This model emphasizes playing to the unique strengths of every member of the theoretical team to utilize their skills and resources in order to achieve the best outcomes of each individual as well as the population. This is supported by evidence that suggests that collaborative care and working in teams has the potential to eliminate duplicative care, encourage a team based model, and increase the ability of each person to work to the full extent of their scope and in their area of expertise ( The Institute, 2017 ). But, in order to build upon the nursing process with a public health approach, it is not only important to increase the actual number of PMHNPs but also to ensure adequate education, training opportunities, and career placement. A number of challenges exist in this process.

Preparing PMHNPs Serving Children and Adolescents

The education and preparation of PMHNPs directly relates to their transition to practice in addition to the educational preparation. Recommendation 3 on implementing nurse residency programs directly ties into this discussion ( IOM, 2011 ).

Reform in Education

Based on the American Association of Nurse Practitioners (AANP) 2017 data, approximately 327 PMHNP training programs (including master’s only, post-master’s, BSN to DNP, and DNP) exist. All programs prepare students for lifespan certification, but each program may vary significantly in terms of child training hours, clinical training opportunities, and child-focused topics (e.g., psychopharmacology, development, physical assessment) ( Vanderhoef & Delaney, 2017 ). Additional challenges include: training in specific psychotherapies as well as transitioning of many master’s level programs to the DNP level, thus creating a need to balance between patient care and quality improvement hours as part of the 1,000 hour curriculum ( Vanderhoef & Delaney, 2017 ). In addition, the provision of pediatric pharmacological and therapeutic interventions is highly specialized and not always clearly delineated by current guidelines (such as through the American Association of Child and Adolescent Psychiatry), thus requiring more explicit didactic preparation and clinical training ( American Association of Child and Adolescent Psychiatry, 2019 ). Furthermore, the increase in distance or online programs may also impact the oversight of clinical training in child and adolescent hours.

For PMHNPs who have an interest in primarily serving child and adolescent populations, training in a program with significant connections to child and adolescent training opportunities (such as at academic training centers with child and adolescent psychiatry fellowships), as well as affiliation with child clinical sites, would be beneficial. In addition, given the comparison to child and adolescent psychiatrists who have either 1) completed a general psychiatry residency and a child psychiatry fellowship or 2) completed a pediatrics residency and a child psychiatry fellowship, the PMHNP interested in working with children and adolescents must engage in additional training opportunities, either informal or formal. Typically psychiatry fellows have the advantage of additional didactic and clinical training ( Kaye et al., 2009 ). Few resources exist for nurse practitioner residencies to date. To the authors’ knowledge, only one pediatric psychiatric nurse practitioner fellowship, Nationwide Children’s Hospital, exists for post-graduate specialty training. Through this program, fellows receive didactic training in psychopharmacology, psychotherapies, quality improvement, evidence based practices, and comprehensive diagnostic assessment and diagnosis. Clinical rotations include: early childhood, inpatient and emergency, primary care, tele-psychiatry, home based care, and primary care ( Nationwide Children’s Hospital, 2019 ). Previously a pediatric psychiatric nurse practitioner fellowship existed at Children’s Hospital of Philadelphia. This residency offered a model for training and included didactic content specific to advanced psychopharmacology, diagnosis of autism spectrum disorders, and family based treatment of eating disorders. Clinical rotations included: diagnosis and assessment clinics, young child clinic, eating disorders clinic, anxiety and mood disorders clinics, and inpatient rotations on consult liaison services and inpatient services.

Overall, the limited availability of training both during and after graduation and certification creates an increased barrier for PMHNPs choosing this specialty area. Universal standards in curriculum, synergy with child and adolescent psychiatry training programs ( Kaye et al., 2009 ), and increased collaboration for the development of child and adolescent training programs, both in academic settings and in the community, are needed to fill this gap.

A proposed residency model for PMHNPs serving children and adolescents would include both didactic and clinical experience with residents expected to carry a reduced but significant patient caseload (approximately 60% to allow time for instruction). Didactic experiences may include: diagnosis and assessment across early childhood and young adulthood, psychopharmacologies, psychotherapies (including parent and family focused therapies), evidenced based practice, quality improvement, collaboration among sectors (such as justice system and schools), and interdisciplinary care. Clinical experiences should include: inpatient experiences (consult liaison, primary care or specialty embedded psychiatry, substance use, medical behavioral units or inpatient units, crisis management, and emergency services) and outpatient experiences (child and family therapy, diagnosis specific clinics, young child clinics, general psychiatry, and eating disorder clinic). Key to such a residency program would be adequate training resources, sites, and instructional support, particularly as it pertains to clinical supervision. In such a model approximately 24 hours per week would be dedicated to patient care and 16 hours per week to didactic instruction, allowing for the concrete development of competency areas over the course of 12 months. Those who complete the fellowship may then be recruited to practice areas in need of child and adolescent PMHNPs. Such a training model, while resource intensive has the potential to prepare new nurse practitioners across multiple specialty areas within child and adolescent psychiatry and mental health.

Role Transition in Clinical Practice

Adopting the framework and approach described from a nursing and public health perspective, the authors recommend that PMHNPs be located in physical locations where children are served, such as schools, rather than in specialty care facilities. The primary goals of care would then be to promote mental health and well-being to all people, regardless of symptom presentation. The second level of care would be for those with emerging symptoms, for example, social anxiety in a school-based setting, requiring therapeutic intervention (e.g., cognitive behavioral therapy to reduce specific anxiety symptoms, like avoidance of the anxiety-provoking stimulus). Finally, the third level of care would be for those with acute symptoms such as suicidality or major depression requiring an intervention including medication, therapy, and/or hospitalization or other levels of care for stabilization.

Such a model would involve not only the PMHNP but also the school nurse, social workers, teachers, parents, and others involved or co-located in the school environment. The model could also be envisioned in a pediatric primary care practice, for example, where all children receive basic interventions; some children with mild symptoms receive additional intervention; and those with acute symptoms receive the traditional psychiatric model of care. Integrating mental health treatment into primary care may serve the dual purpose of supporting primary care providers as well as locating services in a manner that is accessible to patients ( Skokauskas, 2019 ). Mental health integration also offers the promise of creating an environment in which children receive mental health, physical health, social support, and other specialty care under the same umbrella of care ( Tyler, Hulkower, & Kaminski, 2017 ). By segmenting the population in this way, the interventions provided by the PMHNP are team-oriented, service-driven, and non-duplicative of care that a child or adolescent may receive elsewhere. A key example of non-duplicative care is therapy, which may be provided by a social worker, marriage and family therapist, licensed professional counselor, clinical psychologist, psychiatric mental health clinical nurse specialist (CNS), PMHNP, or psychiatrist. Given that therapeutic services may be more widely available than medication management services, medication management should be a primary role for the PMHNP when time and resources are limited. PMHNPs may also spearhead innovative solutions to care such as expanding digital interventions for teens. Creating a model of transition or residency to achieve this role may also be seen as a way to fill the gap in availability of additional child and adolescent nurse practitioner residency programs.

Recommendations for the 2020 – 2030 Future of Nursing Panel

First and foremost, this paper posits that in the current context of the crisis of mental health care facing children and adolescents, the role of the PMHNP must change. Then, it calls for both theoretical and practical shifts to better service children and adolescents with mental health issues.

As the next Future of Nursing panel convenes, we recommend the following actions:

• Changes to recommendation 1: Although we call for an expanded role of the PMHNP that works within the framework of many states, removing scope of practice barriers and addressing variable advanced practice state legislation will benefit PMHNPs serving children and adolescents ( IOM, 2011 , p. 100). This recommendation should occur in conjunction with recommendation 3.
• Changes to recommendations 2 and 7: We recommend that PMHNPs move beyond leading and diffusing collaborative efforts, instead leading to advance health. We call on the Future of Nursing 2020 – 2030 panel to ask for a re-visioning of the role of the PMHNP in order to restructure services to best address the needs of children and adolescents ( IOM, 2011 , p. 95).
• Changes to recommendation 1: We strongly recommend strengthening graduate education of the PMHNP by supporting a nurse residency model and training in currently existing systems that moves towards primary mental healthcare delivery. Education, including nursing education at the graduate level, treats the diagnosis, care, and treatment of patients with mental health disorders as a separate body of knowledge, or “population foci” in the terminology of the Consensus Model for APRN Regulation ( National Council of State Boards of Nursing, & National Council of State Boards of Nursing, 2008 ). We note that the 2011 IOM report does not clarify where they believe mental health care falls on the specialty-primary paradigm, and also encourage that this be addressed in the next report ( IOM, 2011 , p. 163).
• Changes to recommendation 8: We call on the 2020 panel to improve workforce data that provides population specific data on child and adolescent providers. Given that PMHNPs provide lifespan services, tracking may pose challenges, however in order to visualize the care provided, collaboration, and expansion of scope, further data is needed ( IOM, 2011 , p. 259).

Conclusions

The future holds great promise and impact for child and adolescent psychiatric mental health nurse practitioners. We have the potential to improve the health and well-being of a future generation and improve public mental health. Yet, doing so requires a shift in ideology from the delivery of specialty based care to a primary care model - one based in nursing values and informed by the public health approach. Making this ideological shift does not require changes to the PMHNP standard of practice or scope, but does require the PMHNP to engage in collaborative relationships and to integrate many basic and advanced competencies. Expanded scope of practice can likely also encourage this re-visioning of the role. Educators, students, clinicians from other disciplines, policy-makers, and even children and families must advocate for change. The first step for our profession is to obtain more and better data about the demand for services and the current and projected workforce, as well as population-specific data (i.e. geriatric, child and adolescent, carceral). The profession must also seriously review the level of training needed in specialty populations in order to provide appropriate care. Training models, including the master’s and clinical doctorate level preparation and formalized post-graduation options, must seek to address this provider gap as well as make efforts towards increasing the number of nurse practitioners able to practice. By challenging the current status quo of child and adolescent mental health care delivery, PMHNPs can be true leaders in the field and deeply impact the state of mental health for children and adolescents.

Acknowledgments

This research did not have funding support.

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Contributor Information

Aparna Kumar, Thomas Jefferson University, Children’s Hospital of Philadelphia.

Anne Kearney, Children’s Hospital of Philadelphia.

Katelin Hoskins, University of Pennsylvania, School of Nursing, Children’s Hospital of Philadelphia.

Anita Iyengar, University of Pennsylvania, School of Nursing.

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• National Center for Health Workforce Data (2018). HRSA Health Workforce . Behavioral health workforce projections, 2016–2030: Psychiatric nurse practitioners, psychiatric physician assistants . Retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/psychiatric-nurse-practitioners-physician-assistants-2018.pdf [ Google Scholar ]
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BSN to Doctor of Nursing Practice in Psychiatric Mental Health Nurse Practitioner

Application deadline is October 15, 2024.

Apply by October 15 to be considered for next year's cohort.

The online DNP Psychiatric Nurse Practitioner program is designed to prepare graduates for professional roles as psychiatric mental health nurse practitioners (PMHNPs). PMHNPs can provide care for children, adolescents and adults.

Graduates can provide mental health, addiction, and comorbid mental health care in various settings, including primary care, schools, community, and business environments. Nurses completing this specialty of Ohio State’s online BSN to DNP degree program are eligible to take the PMHNP certification examination offered by the American Nurses Credentialing Center.

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Academic Calendar

Ohio State’s online BSN to PMHNP doctorate program admits students once-per-year for the Autumn semester.

Autumn 2025

Application Deadline October 15, 2024

Term Start Date August 26, 2025

Autumn 2026

Application Deadline TBA

Term Start Date August 25, 2026

Admission Criteria

Applicants of the online BSN to DNP – Psychiatric Mental Health Nurse Practitioner program must have the following:

• Active RN license
• Earned Bachelor of Science in Nursing degree
• A minimum of a 3.0 cumulative GPA in the last degree earned relevant to program of study
• PSYCH 2220 Data Analysis in Psychology
• PSYCH 3321 Quantitative and Statistical Methods
• PUBHIBO 6210 Applied Biostatistics I
• STATISTICS 1350 Elementary Statistics
• STATISTICS 1450 Introduction to the Practice of Statistics
• STATISTICS 2450 Introduction to Statistical Analysis

Applications to this online PMHNP program will be reviewed using a holistic approach, meaning all aspects of who you are as an applicant will be considered. This assessment will include academic preparedness and formative experiences in your professional background, education and life.

The State Authorization Reciprocity Agreement, also known as  SARA , establishes uniform standards for distance education for all participating states and institutions. Ohio State joined SARA in 2015, which means Ohio State can offer most online and on-ground courses and programs in  SARA member states, districts and territories without seeking authorization in each state.

What can you do with a Psychiatric Nurse Practitioner DNP degree?

Ohio State’s DNP Psychiatric Nurse Practitioner program curriculum and field experience allow students to provide healthcare to neonates in a variety of settings. This online BSN to DNP program pathway meets the curriculum guidelines of both the National Organization of Nurse Practitioner Faculties and the American Nurses Credentialing Center certification.

NURS 7340 – Neuroscience Principles and Concepts Relevant to Psychiatric Mental Health Nursing

Neurobiological bases of brain-mind-behavior relationships in mental health and illness, including chemical dependence. The promotion, maintenance, and restoration of central nervous system homeostasis will be emphasized.

NURS 7341 – Advanced Psychiatric Mental Health Therapies Across the Lifespan

Advanced nursing clinical therapeutic interventions with persons across the lifespan diagnosed with mental illness and/or substance abuse. Prereq: Grad standing and enrollment in the Psychiatric Mental Health Nursing specialty.

NRSPRCT 8785 – Foundations of Evidence-Based Practice

This course immerses students into the knowledge, principles & skills of evidence-based practice (EBP) integral to preparing the DNP for mentoring & leading EBP in advanced practice settings & in healthcare systems. The content places strong emphasis on the initial steps of the EBP process from organizational assessment & problem identification through making recommendations based on evidence.

NRSPRCT 8898 – DNP Systems Application

Application, integration and synthesis of knowledge, skills, and abilities to meet AACN Essentials for Advanced-Level Nursing Education sub-competencies with practice experiences designed to help students achieve competencies in the specialty components of the DNP role.

Program Faculty

While taking the next step in their nursing careers in this online psychiatric nurse practitioner program, students will learn from and collaborate with world-class faculty and peers from across the country.

Randee Masciola, DNP, APRN-CNP, WHNP-BC, FAANP

Dr. Randee Masciola focuses on prevention, education and health maintenance in regards to women’s health across the life span.

Samantha Ault, PhD, APRN-CNOP, PMHNP-BC

Shannon Linder, DNP, APRN-CNP, FNP-BC, PMHNP-BC

Brandy McKinney, DNP, APRN-BC, PMHNP-BC, FNP-C

Get Started

Speak with a knowledgeable Enrollment Advisor who can help answer your questions and explain different aspects of the more than 70 online degrees and certificates offered at Ohio State.

Psychiatric-Mental Health Nurse Practitioner (PMHNP) Post-Graduate Certificate Program

A Unique School and PMHNP-PGC Program

Complete the Psychiatric-Mental Health Nurse Practitioner Post-Graduate Certificate Program (PMHNP-PGC) to address individual, family and population needs for mental health promotion and prevention.

Experience a curriculum that emphasizes collaborative and holistic, trauma-informed care that is grounded in the principles of resilience and healing. 

Develop PMHNP lifespan clinical competencies across the care continuum. 

Participate with other Georgetown University students and faculty in interdisciplinary discussions addressing complex “wicked” problems impacting human health. 

Develop structural competencies to promote social justice and reduce inequalities in mental health care. 

Advocate for policies that improve mental health care access, quality and equity by collaborating with professional organizations and congressional members in Washington, D.C. Immerse yourself in Georgetown School of Nursing and campus whole person education through exposure to different viewpoints, faiths and cultures.

A Message From the PMHNP-PGC Program Director

Karan Kverno

Comprehensive mental health care services that include community trauma-informed approaches, harm reduction, and recovery support, are in increasing demand nationwide as people deal with issues ranging from acute crises to chronic illnesses or substance use disorders.

The psychiatric-mental health nurse practitioner post-graduate certificate (PMHNP-PGC) program provides master’s and doctorally prepared nurse practitioners with the knowledge and training necessary to deliver mental health care across the lifespan in a variety of clinical settings.

The vision for the program is to support the development of competent PMHNPs that will provide patient-focused, equitable, mental health care. The vision also includes preparing graduates to support patients, families, and communities in addressing social and structural perpetuating risk factors, and to connect those with needs to community resources that help sustain recovery and support resilience.

Thank you for your interest in our program. We look forward to hearing from you as you explore making mental health care part of your practice!

— Karan Kverno, PhD, PMHNP-BC, PMHCNS-BC, FAANP, FAAN

Program Format

The PMHNP-PGC Program’s hybrid format includes asynchronous learning resources, synchronous online class discussions, and two on-campus learning intensives with simulated, standardized patients.

The program emphasizes care of the whole person ( cura personalis ), through individualized evaluation and treatment of symptoms and concerns within the context of unique life circumstances. 

To develop competencies in psychiatric assessment, diagnostic reasoning and evidence-based interventions, students will have clinical practicum experiences in partnership with Medstar Health and other community settings.

Post Graduation Certification

Graduates will be prepared to take the PMHNP certification exams offered by the American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners (AANP).

Course Sequence

Semester 1 fall 1.

Semester 2 Spring 1

Semester 1 Fall 2

Requirements for Admission

The admission requirements for the master’s-level PMHNP post-graduate certificate program are:

• U.S. citizenship or permanent residency
• Current unrestricted U.S. registered nurse (RN) license, and nurse practitioner (NP) license and certification in a primary care specialty. 
• Master of Science in Nursing degree from a CCNE- or ACEN-accredited program
• Minimum 3.0 cumulative GPA and a 3.0 science GPA
• At least one year of full-time NP experience is recommended
• Values consistent with Georgetown University’s Jesuit values and DEIB

As part of the MS in Nursing admission process, the student will also be required to provide the following:

• Professional résumé or curriculum vitae
• Official academic transcripts
• Personal statement
• Recorded interview
• Three letters of recommendation

Connect With Us For More Information

Learn more about Psychiatric-Mental Health Nurse Practitioner Post-Graduate Certificate program by clicking below and completing the form. Our admissions team will contact you with additional information.

Application Deadline

This program admits students once per year in the fall. Applications are now being accepted for the 2025-26 academic year .

Application deadline: January 15, 2025

Tuition and Financial Aid

View current tuition information on the Georgetown University Revenue and Receivables website.

View financial aid information for School of Nursing Graduate Online Students on the Georgetown University Office of Student Financial Services website.

Mental Health and Psychiatric Care Plans

All nursing care plans for Mental Health and Psychiatric Nursing. Topics include: Bipolar Disorders, Schizophrenia, Sexual Assault, Depression, and more.

Impaired Thought Processes & Cognitive Impairment Nursing Care Plan and Management

Effective nursing care planning and management is important for patients with impaired thought process or cognitive impairment as they aim to promote safety, optimize functioning, and enhance quality of life for these individuals. Get to know the nursing assessment, nursing diagnosis, and interventions for patients with cognitive impairment.

3 Personality Disorders Nursing Care Plans

As a nurse, it is essential to understand the nursing diagnosis for personality disorders to provide effective care and support to these patients. In this article, we will discuss the nursing diagnosis for personality disorders in detail, including its definition, types, assessment, interventions, and management strategies.

4 Bipolar Disorders Nursing Care Plans

Learn about the essential nursing diagnosis for bipolar disorder. Explore effective strategies and nursing interventions to provide comprehensive nursing care plans for patients.

5 Alcohol Withdrawal Nursing Care Plans

Alcohol withdrawal refers to symptoms that may occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol. Here are 6 nursing care plans for Alcohol Withdrawal.

5 Anxiety and Panic Disorders Nursing Care Plans

The following are nursing care plans for patients with anxiety and panic disorders.

6 Major Depression Nursing Care Plans

Included in this nursing care plan guide are nine (9) nursing diagnosis for major depression.

6 Schizophrenia Nursing Care Plans

In this guide are nursing care plans for schizophrenia including six nursing diagnosis. Nursing care plan goals for schizophrenia involves recognizing schizophrenia, establishing trust and rapport, maximizing the level of functioning, assessing positive and negative symptoms, assessing medical history and evaluating support system.

6 Suicidal Ideation (Hopelessness & Impaired Coping) Nursing Care Plans

Learn about the care for patients with suicidal ideations in this care plan guide.

7 Substance Abuse Nursing Care Plans

Substance abuse, or also known as drug abuse, is a disorder of continuum of phases incorporating a cluster of cognitive, behavioral, and physiological symptoms that include loss of control over use of the substance and a continued use of the substance despite adverse consequences.

Acute Confusion (Delirium) and Altered Mental Status Nursing Care Plan

Nurses play a crucial role in the care of patients with confusion and altered mental status, and their nursing care plan should be individualized to the patient’s needs and circumstances.

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Psychiatric Mental Health Nurse Practitioner

Admits only in the fall

The Psychiatric Mental Health Nurse Practitioner (PMHNP) program provides educational content and clinical experiences that focus on complex psychiatric nursing assessments and interventions for acute and chronic mental health conditions in children, adolescents, adults, and older adults. The curriculum has an emphasis on holistic care, integrated mental health, cultural sensitivity, and substance treatment. Coursework includes psychotherapy, neurobiology, and psychopharmacology content for patients across the lifespan. The PMHNP faculty are experts in the field with a broad range of clinical and research expertise. There is a high demand for PMHNPs in Colorado and across the country. The PMHNP program prepares graduates to provide a full range of psychiatric services and work in a variety of practice settings.

PMHNP Program Highlights

• Online and blended coursework with on-campus intensives
• Cohort model encourages student connections and community building
• Clinical placements are provided for students who live in the Denver metro area
• PMHNP faculty are highly experienced with a broad range of practice specialties, successful research agendas, and mental health policy influence
• Numerous Substance Abuse and Mental Health Services Administration (SAMHSA) Minority Fellows
• Outstanding record of first-time pass rates on the PMHNP ANCC national certification exam
• Graduates are in high demand and find employment quickly

Graduates of this specialty track are eligible to apply for national certification by examination. You will learn more about the certification organizations appropriate for this specialty during the completion of your program. Upon successful completion of the certification examination, Psychiatric Mental Health Nurse Practitioners are eligible for licensure in all 50 states, including Colorado (visit the Colorado Board of Nursing APRN application forms page), where licensure is granted as an Advanced Practice Registered Nurse (APRN) and is required for practice.

• Plans of Study
• Admission Requirements
• Post-Graduate Certificate Information
• Resource Articles

Psychiatric Mental Health Nurse Practitioner Current Plans of Study

• MS: Plan of Study (PDF)
• BS to DNP: Plan of Study (PDF)
• Post-Graduate Certificate: Plan of Study (PDF)
• Master's requirements
• BS to DNP requirements
• Post-Graduate Certificate requirements

A post-graduate certificate is available in this specialty.

Gainful Employment and Program Statistics for Post-Graduate Certificate

For more information regarding graduation rates, the median debt of students completing our certificate programs, and other important information, please visit the University of Colorado Denver Office of Institutional Research and Effectiveness .

American Psychiatric Nurses Association 12/2022: Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis

American Association of Nurse Practitioners 12/2019: Are You Considering a Career as Psychiatric Mental Health Nurse Practitioner?

How long will it take to complete the PMHNP program?

• PMHNP MSN program is 52 credits and is typically completed in 7 semesters (2.5 years)
• PMHNP DNP program is 64 credits and is typically completed in 10 semesters (4.5 years)
• PMHNP post-graduate certificate is 29 credits and is typically completed in 4 semesters (1.5 years).

Does this program have a clinical requirement?

Yes. The PMHNP requires 14 credits of clinical experience which equals 630 contact hours.

Is the PMHNP program offered completely on-line or in-class?

Will i be required to travel to colorado, will this program prepare me to sit for the ancc certification as a psychiatric mental health nurse practitioner, can i take a course before i apply, are there any expectations outside of the classroom.

The PMHNP program is rigorous, challenging, and very rewarding. During the clinical courses, it is strongly recommended that students do not work or work as little as possible.

The National Organization of Nurse Practitioner Faculty (NONPF) has published core competencies in each specialty for students to achieve. Students may need to increase their clinical credits if they do not achieve these competencies within the required clinical credits.

All students are required to have a current and unencumbered RN license, current immunizations, and basic life support.

Lingering Effects of COVID-19

Read: CU Nursing Faculty Study Lasting Impacts of the Pandemic

Kerry Peterson, PhD, DNP, PMHCNS-BC, PMHNP-BC, FAANP Associate Professor of Clinical Teaching, and Director of Psychiatric Mental Health Nurse Practitioner Program

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Mental Health Nursing Diagnosis & Care Plan

Mental health is an essential aspect of overall health and involves a person’s psychological, emotional, and social well-being. It affects the way a person feels, thinks, and acts and determines how a person relates to others, handles stress, and makes decisions. 

Mental health problems or illnesses can arise anytime throughout a person’s life. Various factors give rise to mental health illnesses including biological factors like genes, environmental factors such as toxins, alcohol, and drugs, family history of mental health illnesses, and life experiences like abuse or trauma. 

Signs and symptoms of mental health problems include:

• Inability to concentrate
• Excessive fear
• Excessive guilt
• Withdrawal from society
• Extreme mood changes
• Detachment from reality
• Inability to cope with problems
• Trouble relating to other people or situations

Fortunately, discussions surrounding mental health are becoming more common and resources are readily available to manage mental health disorders.

The Nursing Process

Physical assessments, laboratory tests like thyroid tests and drug or alcohol screening, and psychological evaluations are conducted to help diagnose or rule out mental health problems. 

While it can be difficult to determine the type of mental health problem a person has, an accurate diagnosis will help guide the most appropriate treatment for the patient. 

Medications like antidepressants, mood stabilizers, and antipsychotic drugs are prescribed to help improve symptoms. Psychotherapy, brain-stimulation treatments, and inpatient treatment programs may also be indicated. 

Nurses, regardless of specialty, care for patients who display signs of or are at risk of developing mental health problems. Nurses are instrumental in the assessment, management, education, and collaboration of a patient’s mental health.

Nursing Care Plans Related to Mental Health Disorders

Disturbed thought processes care plan.

Mental health problems affect a person’s mood, thoughts, and behavior. Certain mental health disorders may result in disturbed thought processes where the patient experiences alterations in cognition, perception, reasoning, and problem-solving, interfering with their daily life.

Nursing Diagnosis: Disturbed Thought Processes

Related to:

• Altered self-concept
• Cognitive dysfunction
• Low self-esteem
• Psychological barriers
• Substance misuse
• Unaddressed trauma 
• Social Isolation

As evidenced by:

• Absence of eye contact
• Inaccurate interpretation of stimuli (external or internal)
• Decreased willingness to participate in social interactions
• Difficulty comprehending communication
• Inappropriate social behavior
• Cognitive dissonance
• Inappropriate verbalization
• Speech abnormalities
• Hallucinations/delusions
• Distractibility
• Suspiciousness

Expected Outcomes:

• The patient will maintain reality orientation and communicate and interact with other people according to social norms
• The patient will recognize and implement strategies to manage hallucinations/delusions

Disturbed Thought Processes Assessment

1. Assess the patient’s past medical history and identify factors present. Proper assessment of the patient’s medical history and factors contributing to the patient’s condition is important to help plan the best treatment regimen. Conditions such as dementia , anoxic brain injuries, and schizophrenia may cause disturbed thought processes and all have very different treatments.

2. Assess and review laboratory values. Mental health problems can be caused by biochemical imbalances. Abnormal laboratory values like hypokalemia , anemia , signs of infection, or metabolic alkalosis can indicate causative factors of the patient’s condition.

3. Assess the patient’s cognitive ability. This will help determine the patient’s ability to participate in the plan of care and treatment regimen.

Disturbed Thought Processes Interventions

1. Reorient the patient to person, place, and time as necessary. When a patient is unable to maintain reality orientation, it can cause anxiety or worsening confusion . Consistent reorientation allows the patient to develop a sense of control and builds a trusting relationship with the healthcare provider.

2. Provide safety measures as needed. It is always important to consider the patient’s safety at all times since mental health problems can affect the patient’s reactions to external stimuli. Safety measures include side rails, close supervision, or seizure precautions as indicated.

3. Schedule structured tasks with adequate rest periods. This will help provide adequate stimulation and appropriate treatment interventions while allowing the patient to rest to reduce fatigue .

4. Maintain a quiet and calm environment and approach the patient slowly and calmly. Patients with disturbed thought processes may respond with exaggerated or aggressive behaviors if overstimulated.

5. Do not challenge or accept illogical thinking. Patients who express delusions should not have their reality challenged, but the nurse can offer understanding of what the patient is experiencing while maintaining reality.

6. Teach how to stop negative thinking. Teach the patient strategies such as stating “stop!” or a loud noise such as clapping to interrupt unwanted thoughts.

Ineffective Coping Care Plan

Patients suffering from mental health disorders may fail to effectively deal with existing problems due to unmanaged stress, poor coping skills, or other life pressures.

Nursing Diagnosis: Ineffective Coping

• Inadequate confidence in the ability to deal with a situation
• Inadequate sense of control
• Inadequate social support
• Ineffective tension release strategies
• Inadequate resources
• Altered attention
• Altered communication pattern
• Destructive behaviors
• Difficulty organizing information
• Inability to ask for help
• Lack of goal-directed behavior
• Inadequate follow-through
• Inadequate problem-solving skills
• Substance abuse
• The patient will demonstrate effective coping when faced with unfavorable situations
• The patient will verbalize confidence in dealing with psychosocial issues

Ineffective Coping Assessment

1. Assess history of coping. The nurse can first assess how the patient has coped in the past with difficult situations. The patient may not be equipped with the necessary skills and strategies to cope effectively.

2. Assess for possible causes of ineffective coping. Lack of problem-solving skills, poor self-concept, lack of social support, or stressors such as finances, living environment, or career pressures will each require their own specific strategies.

3. Assess for destructive habits. Ineffective coping may be made worse by the use of drugs, alcohol, overeating, sexual behavior, smoking , and more that require treatment.

Ineffective Coping Interventions

1. Establish trust and a therapeutic relationship with the patient. An unbiased attitude establishes trust. An open and patient tone will reduce feelings of isolation and ultimately facilitate coping.

2. Assist the patient in setting realistic goals. Patients may feel helpless in goal-setting especially if they never reach goals. Instruct the patient on how to set short, manageable goals.

3. Allow the patient to express their fears, feelings, concerns, and expectations. Verbalization of perceived or actual threats can help reduce anxiety and promote open communication with the patient. These should be met without judgment from the healthcare team.

4. Support relaxation and leisure activities. Coping with stress, grief, or other mental health issues requires time for hobbies, exercise, and distraction. Remind the patient to take time to read, write, walk, and enjoy activities.

5. Encourage therapy and counseling. Mental health professionals can help the patient learn and implement healthy coping mechanisms.

Chronic Low Self-esteem Care Plan

Chronic low self-esteem refers to a long-standing negative perception of self-worth and personal abilities. Low self-esteem may be experienced by patients with various mental health disorders such as anxiety disorders, eating disorders, major depressive disorders, and alcohol and drug abuse.

Nursing Diagnosis: Chronic Low Self-esteem

• Disturbed body image
• Fear of rejection
• Ineffective communication skills
• Insufficient approval from others
• Low self-efficacy
• Abandonment
• Domestic abuse
• Depressive symptoms
• Excessive shame or guilt
• Constant seeking of reassurance
• Hopelessness
• Passive behavior
• Overly-conforming behaviors
• Reduced eye contact
• Rejects positive feedback
• Reports repeated failures
• Self-negating verbalizations
• The patient will verbalize an increased sense of self-worth
• The patient will demonstrate behaviors of improved self-esteem such as eye contact, appropriate physical appearance, posture, and participation in conversations

Chronic Low Self-esteem Assessment

1. Assess the patient’s past and current achievements. This shows the patient a more realistic view of his or her strengths and capabilities. Patients with mental health conditions may lose sight of their past accomplishments and tend to exhibit low self-esteem.

2. Assess how the patient views themselves. Assess for negative self-talk and exaggerated feelings of one’s self. The goal isn’t to reject the patient’s feelings but to gain insight into their view of themself.

3. Assess support systems. A lack of support can contribute to poor self-worth. A present support system that is degrading or harmful to the patient’s self-esteem may require intervention.

4. Assess for suicidal ideation. Patients with chronic low self-esteem may have suicidal thoughts or a plan. Ask directly if the patient is thinking of killing or harming themselves.

Chronic Low Self-esteem Interventions

1. Focus on what can be controlled. A chronic sense of failure may need to be overcome. The patient may feel that their every action or entire life is a failure. Attempt to have the patient focus only on what can be controlled, and that what may be deemed a “failure” does not have to be tied with one’s sense of self.

2. Apply active listening and open-ended questions. Therapeutic communication is an important aspect of providing care and support to patients suffering from mental health problems. Communication methods like active listening and using open-ended questions enable the patient to verbalize interests, worries, concerns, and thoughts without interruption.

3. Provide positive feedback and reinforcement. Continuous positive feedback and support promote the patient’s self-esteem and self-worth. In time, the patient will hopefully begin to believe and be a source of their own positive feedback.

4. Teach the patient to recognize and shut down negative self-talk. Recognition of negative thoughts enables the patient to develop new ways of coping. The patient can be taught to replace negative ideas and beliefs with positive affirmations.

References and Sources

• About Mental Health Problems. Mental Health Foundation. 2022. https://www.mentalhealth.org.uk/explore-mental-health/about-mental-health-problems
• Mental Disorders. World Health Organization. 2022. https://www.who.int/news-room/fact-sheets/detail/mental-disorders
• Moitra M, Santomauro D, Collins PY, Vos T, Whiteford H, et al. (2022) The global gap in treatment coverage for major depressive disorder in 84 countries from 2000–2019: A systematic review and Bayesian meta-regression analysis. PLOS Medicine 19(2): e1003901. https://doi.org/10.1371/journal.pmed.1003901
• Psychiatric Mental Health Nursing Concepts of Care and Evidence-Based Practice. 8th Edition. Mary C. Townsend, DSN, PMHCNS-BC. 2015. FA Davis Company.
• What is Mental Health? MentalHealth.gov. Last Updated: 02/28/2022. https://www.mentalhealth.gov/basics/what-is-mental-health

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Shots - Health News

Insurers can restrict mental health care. what laws protect patients in your state.

Annie Waldman

Maya Miller

Interference by insurers is driving mental health care providers to flee networks. It makes treatment hard to find. Some states are passing laws to protect patients. Javi Sanz/Getty Images/E+ hide caption

Accessing mental health care can be a harrowing ordeal. Even if a patient finds a therapist in their network, their insurance company can overrule that therapist and decide the prescribed treatment isn’t medically necessary.

This kind of interference is driving mental health professionals to flee networks, which makes treatment hard to find and puts patients in harm’s way.

ProPublica sought to understand what legal protections patients have against insurers impeding their mental health care.

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Most Americans — more than 164 million of them — have insurance plans through employers . These are generally regulated by federal law.

Although the law requires insurers to offer the same access to mental health care as to physical care, it doesn’t require them to rely on evidence-based guidelines or those endorsed by professional societies in determining medical necessity. Instead, when deciding what to pay for, the government allows insurers to set their own standards.

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“If insurers are allowed to home bake their own medical necessity standards, you can pretty much bet that they’re going to be infected by financial conflicts of interest,” said California psychotherapist and attorney Meiram Bendat, who specializes in protecting access to mental health treatment.

Federal lawmakers who want to boost patient protections could look to their counterparts in states who are pioneering stronger laws.

Although these state laws govern only plans under state jurisdiction, such as individual or small-group policies purchased through state marketplaces, experts told ProPublica they could, when enforced, serve as a model for broader legislation.

“States are laboratories for innovation,” said Lauren Finke, senior director of policy at The Kennedy Forum, a nonprofit that has advocated for state legislation that improves access to mental health care. “States can take it forward and use it for proof of concept, and then that can absolutely be reflected at the federal level.”

ProPublica reporters delved into the laws in all 50 states to determine how some are trying to chart new paths to secure mental health care access.

Many of the new protections are only just starting to be enforced, but ProPublica found that a few states have begun punishing companies for violations and forcing them into compliance.

Who defines what mental health care is necessary?

Insurers generally face few limitations on how they define what kind of mental health care is medically necessary. They often create their own internal standards instead of relying on ones developed by nonprofit professional medical societies. These standards can then be used to challenge diagnoses or treatment plans.

“Knowing the profit motive that insurers have, it’s really shocking that federal law doesn’t define medical necessity and require the use of nonprofit guidelines to make decisions,” said Bendat, who helped California legislators draft a more robust law that passed in 2020, becoming one of the first states to do so.

California’s law requires insurers to follow generally accepted standards of care for mental health and substance use conditions, forcing them to rely on evidence-based sources that establish criteria, such as nonprofit professional organizations or peer-reviewed studies. The state also barred insurers from covering only the treatment of short-term or acute symptoms, such as crisis stabilization, instead of the underlying condition, like chronic depression.

Last October, California found health care organization Kaiser Permanente in violation of the new state law and other health care regulations, reaching a settlement with the company, which agreed to pay a $50 million fine and make $150 million in investments in behavioral health care. A Kaiser spokesperson said that the company takes full accountability for its performance and that it had adopted new guidelines in line with the law. (Read their full response .)

A spokesperson for the state’s Department of Managed Health Care said the agency is auditing insurers and determining whether their networks offer enough providers to serve customers and whether they deliver timely access to care.

Nine states, including Oregon , Illinois and Georgia , have defined the clinical standards or criteria that insurers must use when making coverage decisions on mental health care.

Amid the opioid crisis, which has killed more than a million Americans, states have also instituted medical necessity protections for substance use treatment. For example, in Colorado , Maryland , Delaware , Connecticut and several other states, insurers must rely on guidelines from the American Society of Addiction Medicine when reviewing treatments for substance use.

How can insurers challenge mental health treatment?

Before 2008, insurance companies nationwide could put more stringent limits on how often patients got mental health care compared with medical care, instituting more restrictive caps on the number of therapy sessions per year or the length of a stay at an inpatient facility.

The federal Mental Health Parity and Addiction Equity Act banned those harder limits. So insurers shifted to a different way to deny care. “They’re not going to just cover unlimited care, so they have to do something to limit utilization,” said Tim Clement, the vice president of federal government affairs at the nonprofit group Mental Health America.

Insurers say they conduct what they call utilization reviews , in which they can request and sift through therapy progress notes full of sensitive details, to assess whether providers are delivering appropriate care. However, providers, mental health care advocates and legislators have found that these reviews are often used as pretexts by insurers looking for a reason to dispute the necessity of treatment.

In recent years, at least 24 states have passed legislation to try to regulate how insurers conduct reviews of behavioral health care.

After the New York attorney general determined that insurers, including EmblemHealth, Excellus and MVP, had violated state and federal laws with their reviews, state legislators bolstered oversight of these processes in 2019. An Excellus spokesperson said it had since adopted several reforms; MVP did not respond to ProPublica’s questions, and EmblemHealth forwarded a response from a managed health plan trade group called the New York Health Plan Association, which said that the state’s findings do not reflect the industry’s current practices. (Read their full responses .)

The New York law requires insurers to rely on criteria based on evidence and approved by the state when scrutinizing care. Peer reviewers, who work for insurance companies to assess medical necessity or appropriateness of care, must be licensed providers with relevant expertise in mental health. And when it comes to children, insurers are generally prohibited from requiring preapproval for their mental health treatment or conducting reviews during the first two weeks of an inpatient stay.

Last year, New York regulators found that Cigna’s and Wellfleet’s medical necessity criteria were out of compliance with the new law. The insurers are allowed to keep operating while they work with the state to bring their criteria in line with the law, according to the state’s mental health office. (The companies did not respond to requests for comment.)

Several states, such as Massachusetts , New Mexico and Hawaii , make insurers disclose to patients and providers the criteria or policies that they rely on for reviews.

Insurers usually select the clinician conducting reviews, but in Illinois, if there’s a disagreement about the necessity of a treatment, a patient can opt for another clinical reviewer, jointly selected by the patient, their provider and the insurer.

Some states have also limited the frequency of reviews. In Delaware, insurers are generally prohibited from reviewing inpatient substance use treatment in the first 14 days. In Kentucky and Ohio , for patients with autism, insurers cannot request more than one review annually for outpatient care.

What must insurers reveal about mental health care access?

It can be hard to enforce the laws requiring equitable coverage for mental and physical conditions; doing so entails comparing very different kinds of health care and successfully arguing there is an imbalance in access. State and federal regulators also have minimal resources for such intensive examinations, which has hindered their ability to scrutinize insurers.

To hold insurers accountable, at least 31 states and the District of Columbia have passed laws requiring them to report how much access they really provide to mental health care.

Most of these states ask insurers to provide details on their treatment criteria or limitations, but some states appear to be violating their own laws by not posting information publicly.

New Jersey’s Department of Banking and Insurance, for example, must make an insurer complaint log publicly available and post an insurance compliance report related to mental health care. But no such information has been published on its website more than five years after the state passed this requirement.

After ProPublica asked about the lack of transparency, spokesperson Dawn Thomas said that the department is working to implement the requirements and that the reporting process would begin this year. “We recognize that the reporting provisions in the law provide important public insight into compliance of carriers,” she told ProPublica in an email.

Chris Aikin, a spokesperson for the original bill’s primary sponsor, New Jersey Assembly Speaker Craig Coughlin, told ProPublica his office had been in contact with the department and would “monitor their progress to meet reporting requirements and ensure full transparency for consumers.”

For compliance reports, states often request data and analyses from insurers, but the figures that insurers submit may not be detailed or even accurate.

“I’ve reviewed a lot of these analyses,” said Clement, who has helped advocate for greater insurer transparency in multiple states, “and in most states, they’re pretty bad.”

But in some states, like Oregon, where detailed annual reporting is required, analyses revealed a disproportionate number of insurance claims for behavioral health were out-of-network compared with medical claims, suggesting that people may have faced trouble accessing therapists covered by their insurance plans.

Its reports also found that mental health providers were paid substantially less than medical providers for office visits of equivalent length. For an hourlong office visit, a mental health provider was, on average, reimbursed about half the amount given to a medical or surgical clinician. A spokesperson for the state’s Department of Consumer and Business Services told ProPublica that there have been no investigations or enforcement actions in response to the new requirements.

“There’s no way we can feel confident that anyone is following the law unless we make sure there is accountability and they have to prove that they’re accountable,” Clement said.

Other states, like New York, have begun to use the new data to drive investigations. Since 2021, the state’s Department of Financial Services has conducted nine investigations of seven insurance companies in response to the laws, according to a department spokesperson.

People can file complaints with their state insurance departments if they believe that an insurer is violating their rights.

This story comes from ProPublica, a nonprofit newsroom that investigates abuses of power. 

Share your story: If you have submitted a complaint to a state insurance department that you would like to share with ProPublica reporters, reach out at [email protected] . 

ProPublica reviewed laws and regulations in all 50 states and the District of Columbia. If you see a state law that was not included, please send them a note.

Max Blau of ProPublica contributed research to this report. Maps by NPR’s Connie Hanzhang Jin.

• health insurers
• mental health parity
• mental health care

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