Home > RNJ > 2007 > May/June > Editorial: Seeing the Unseen

Editorial: Seeing the Unseen
Elaine Tilka Miller, DNS RN CRRN FAHA FAAN Editor

It is relatively easy to identify the physical limitations of our patients, but what about those unseen dimensions? As we care for our patients, how often are mental health issues missed?

Internationally and in the United States, mental health disorders are common among all races, ages, religions, incomes and genders. It is estimated that over 26% of Americans aged 18 and older (i.e., 1 in 4 adults), suffer from a diagnosable mental health disorder in a given year (nimh, 2007). With regard to severe mental illness, the statistics indicate that 1 in 17 Americans fall into this category (Kessler, Chiu, & Walters, 2005).

So, what are the broad categories of mental disorders in America and why is this important to rehabilitation nursing? According to the National Institute of Mental Health (2007) the broad mental health disorders include mood disorders (i.e., depression, bipolar disorder, and suicide), schizophrenia, anxiety disorders, eating disorders, attention deficit, hyperactivity, autism, and Alzheimer’s disease. Mental illnesses are treatable conditions that can disrupt a person’s thinking, mood, ability to interact with others and daily functioning, but also have an important effect on rehabilitation outcomes.

When providing care, how often do we consider the impact of diagnosed or undiagnosed mental health disorders as we plan our care, execute treatment regimens, implement educational programs, and assess adherence to medication and lifestyle changes? If 1 in 4 Americans suffer from mental health disorders, it may not be totally unreasonable to speculate that given the multiple stressors experienced by patients requiring rehabilitation, the numbers of our patients with mental health disorders could elevate to well over 50%.

Consider Melanie, an American soldier, serving in Iraq who experienced an above the knee amputation (AKA). She was admitted for rehabilitation and follow-up care, but wakes at night reliving the assault on her vehicle that resulted in her injury and the death of two other soldiers. Along with the AKA, she is suffering from post-traumatic stress disorder that affects approximately 7.7 million American adults in a given year (Kessler, Chiu, & Walters, 2005) as well as depression related to the loss of her leg. Fortunately, Melanie’s mental health conditions were diagnosed and a comprehensive regimen planned to address her mental conditions. However, what about all those other patients that we care for whose mental disorders are not identified and treated?

As you read this issue, how many of the patients could be experiencing common mental health disorders such as depression and anxiety that were not considered, but could have significant effects on outcomes of care? A blend of reasons may occur for missing these conditions such as patients not being comfortable sharing their true emotions, not wanting to bother the healthcare practitioners (HCPs), not being in touch with what they are experiencing, and our inability as HCPs to recognize and effectively respond to signs of mental health conditions. Because rehabilitation nurses are committed to promoting the highest level of function in our patients, we must consistently consider the physical, as well as mental health, aspects that have short and long-term ramifications to both patients and their families.

As we reflect on our settings and the influence of mental health disorders on our practice, there are several important actions we can take. For instance, how many of our patients have diagnosed mental disorders and how many in retrospect may have had common mental disorders that were missed? After we have a greater sense of the numbers, what actions need to be taken to improve the mental health care of our patients? Should all rehabilitation patients routinely receive mental/emotional assessments in both inpatient and outpatient settings? Should we establish additional collaborative and long-term relationships with mental health professions? Do we need to require more consistent and comprehensive educational mental health programs for rehabilitation nurses and other HCPs? Is there still a stigma associated with mental health disorders that contribute to the delay in the recognition and evaluation of patients?

Mental health disorders are not like physical illnesses and require a different type of professional knowledge. As a result rehabilitation nurses and other HCPs need to recognize and accept that the strategies for prevention and management must differ. Moreover, for all of our patients, mental health issues need to always remain at the forefront.


Kessler, R.C., Chiu, W. T., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Prelication (NCS-R). Archives of General Psychiatry, 62(6), 617–627.

National Institute of Mental Health. (2007). The numbers count: Mental disorders in America. (www.nimh.nih.gov publicat/numbers.cfm#intro, retrieved 2/28/2007).