CHAPTER ONE

INTRODUCTION

1.1 Background of Study

Psychiatric illness has fascinated and confounded healers, scientist and philosopher for
centuries, it symptoms have been attributed to possession by demons considered to be
punishment by the gods for the evil done or accepted as evidence of the inhumanity of it
suffering victims. Thus explanation resulted in enduring stigma for those whose were
diagnosed with such disorders. Even today, much of the sigma persist although it has less
to do with demonic possession than with society’s unwillingness to shoulder the
tremendous cost associated with mental illness.

Relapse is one of the most severe problem of mental health care givers. It is common in
about 1.3% of the already treated cases of mental illness or more than two million people
(U.S. Department of Health and Human Services [USDHHS] 2016). Its economic cost is
envious. Direct cost of relapse treatment expenses of most psychiatric illness were
estimated 2.5% of the total treatment of first hand mental illness care budget in 2015
(American Psychiatric Association [APA] 2017).

The last year for which these data were available (USDHHS, 2016). In 2018, this
accountant for $23.6 billion of mental health care dollar spent. The indirect cost such as
loss of wages, premature death and incarceration were estimated to be $46 billion in the
first half of 2018 (APA, 2017).

Further unemployment among permanent disability is 10% (APA 2019). The cost relapse
in terms of individuals and family suffering are probably inestimable.

Despite the current trend in modern treatment, there is still an alarming rate of relapse
and the reoccurrence of psychiatric illness globally. Individual who ought to be
productive and responsible in life are wasting away on daily basis.

Today patients are required to stay for a short period of time in the hospital admission
and discharge to home environment to help reduce dependency on the hospital care and
 reducing relapse. Also this helps to reduce stigmatization and prevent complications
(Feyinsayo, A. 2015). This study will attempt an overview of Nurse and also to show
how proper utilization of psychiatric Nursing service will go a long way in reducing and
eradicating the ever growing cases of relapse among psychiatric patients in Federal
Neuropsychiatric Hospital Dawanau, Kano.

1.2 Statement of the Problem

The frequency of patients having readmission into the hospital over the last few years has
become a problem. This has made the achievement of good control of patients’ symptoms
and cure impossible.

Nursing Staff and the Hospital has suffered frustration seeing the readmission of patients,
whom were recently discharged home after being stabilized on admission. Some patient
relapse as soon as they are discharged home. Other on trials discharge relapse while other
still relapse while on admission. Various factors ranging from financial problems, lack of
adequate staff have contributed to the relapse of patients.

Some patients have about a day or two days journey distance to the hospital resulting in
poor monitoring and accessibility to the mental health services. Other factors also include
stigmatization and dependency on care giver. All these have contributed in the frequency
of relapse experienced in the care of these groups of patient leading to the social
disability.

Hence, resulting in the following:

a) Low manpower
b) Untold hardship
c) Financial constraints
d) Societal nuisance

If not properly handled and solutions found, the economy may suffer and the society will
be at a loss apart from the untold hardship. This is what motivated the researcher to
investigate the cause, give suggestions, remedy the situation and also reduce the high rate
of relapse.
1.3 Objectives of the Study

1. To evaluate the relationship between the educational background of the Nurses

and their attitude towards prevention of relapse.

2. To ascertain he relationship between the status of the Nurse and her ability to
prevent relapse among psychiatric patients.

3. To determine the relationship between the experience of the Nurse and their
ability to identify symptoms of relapse.

4. To find out whether poverty can predispose psychiatric patient to relapse.

5. To determine the relationship between drug compliance among psychiatric patient

and relapse prevention.

1.4 Significance of the Study

The significance of this study is to help Nurses develop a positive attitude towards the
care to the psychiatric patient thereby reducing the incidence of relapse.

1.5 Research Questions

1. What is the relationship between the educational background of the Nurse and
their attitude toward relapse prevention?
2. What is the ability of the Nurse towards Relapse prevention among psychiatric
patients?
3. What is the experience of the Nurse toward identifying symptoms of relapse?
4. Can poverty predispose psychiatric patients to relapse?
5. Can drug compliance prevent relapse among psychiatric patient?
1.6 Scope of the Study

The scope of this study is restricted to Federal Neuropsychiatric Hospital Dawanau, Kano
which is one of the tertiary healthcare institutions owned by the federal Government of
Nigeria.

1.7 Limitation of the Study

Financial Constraint as there is no adequate Funds.

The limitations of this study were due to lack of time due to the limited time within
which the study had to be carried out.

1.8 Operational Definition of Terms

1. Attitude: The way you think and feel about something.

2. Disability: Any restriction or lack of ability to perform an activity in the manner
or within the range considered normal for a human being.
3. Management: The process of treatment or control of disease or disorders or the
care of patient who suffer them.
4. Nurse: A person whose job is to care for people who are ill.
5. Psychiatric Nursing: This is a branch of medicine that deals with the prevention,
treatments, diagnosis, cause of mental illness.
6. Prevention: To keep away from happening or arising of stop from occurring.
7. Psychiatric Patient: Person who suffers from mental illness which could be
minor or major.
8. Rehabilitation: Restore to effectiveness or normal life by training especially after
illness.
9. Relapse: The return of disease after an interval of convalescence.
 CHAPTER TWO
REVIEW OF LITERATURE
2.0 Introduction
This chapter deals with the review of relation literature and is based on Attitude of Nurse
toward Relapse Prevention among psychiatric patients in Federal Neuropsychiatric
hospital Dawanau.
2.1 Conceptual Framework
2.1.1 Psychiatric Illness
Psychiatric illness comprises of various disorder with some common features. These
common features include disturbances in thinking and occupation with self and inner
fantasies. The person with a psychiatric disorder may live in a private world. A world
inhabited by voices that condemns or accuses the person vile acts and by vision of
frightening. The person may be totally withdrawn from external environment and may be
preoccupied with an internal fantasy life.

Mary Ann Boyd (2015) defined relapse as a return of the illness symptom which are
severe enough tot disrupt daily activities or require unscheduled in patient or outpatient
intervention.

Herz (2017) outlined five phases, relapse for psychosis, these are:

1. Over Extension: In this phase, patients feel estranged from self and the
environment. He/She no longer understands himself (de personification).
2. Boredom and Apathy: Patients become easily tired and withdrawn, there is a bit
of clouding of consciousness here.
3. Disinhibiting: There is return of consciousness, patients has paranoid idea,
accuses others etc.
4. Disorganization: Patients becomes chaotic sees, hears and believes in all manner
of things.
5. Resolution: He no longer question beliefs but act on them.

According to Barbara Schoen Johnson (2016), Non-compliance with medications,

indulging in alcohol and drug abuses are commonly related to the frequency of re
 hospitalizations. Client’s education about the importance of the following medication
regimes and abstaining from alcohol and other substances have been shown to lengthen
the time between hospitalizations.

Denzin (2018) described four stages of relapse as it affect drug. They are:

1. The person engages in permissive thinking, feeling that it is alright to quiet old
haunts.
2. Engaging in substance use in a situation where one feels compelled to use it.
3. Realizing the need for help and getting it.

Sadock and Sadock (2015) suggest that the term of chronic mental illness, which
historically has been associated with long hospitalizations that resulted in loss of social
skills and increased dependency. These individuals may never have experienced
hospitalization but they still do not possess adequate skill to live productive lives with the
society.

In 2019, the joint commission on mental health and illness was established by congress to
identify the nations mental health needs and to make recommendations for improvement
in psychiatric care.

2.1.2 Concept of Attitude

Attitude is a positive or negative evaluation of people, objects, event, activities, ideas or

just about anything in the environment. Attitude is also defined as psychological
tendency expressed by evaluating a particular entity with the same degree of favour or
disfavor (Eagle and Chaiten, 2015). Attitude can also be said to be an expression of
favour or disfavour towards a person, place, thing or event (the attitude object).
Prominent Psychologist Gordon Allpoit (2016) further said that the distinctive and
indispensable concept in contemporary social psychology is attitude.

The concept of attitude do not adequately distinguish between attitude and factual beliefs
on the one hand or between attitude and preference on the other hand. To hold an attitude
is to ascribe an objective moral property to the attitude objective, however, the concept of
such properties rests on incoherent theory of relations as constitutive of their term and the
 belief in them has also pseudo-cognitive content. Moralism or th1e maintaining of
attitude is a special technique for distinguishing and promoting interest. Attitude serves
as rationalizations for concealed or unconscious impulses and themselves defensive by
further rationalization.

Attitude formation occurs through classical conditioning, operant conditioning and

modeling as it occur to Nurse who is psychologically, socially, culturally bound to his to
her community, family and the society they live, this will invariably affect the way they
care for their patients.

According to Mary Ann Boyd (2019) defined relapse as a return of the illness symptom
which are severe enough to disrupt daily activities or required unscheduled in patient or
outpatient intervention.

2.1.3 Causes of Relapse

 Patient may not be getting enough rest;

 The patient may not be taking their medications properly as prescribed;
 The patients may be under more stress than usual;
 They may have started another drug form a different health problem which may
interfere with the existing drugs;
 In some cases availability of drug in the case of drug abuse can predispose a
patient to relapse;
 Social influence is a cause due to pressure exerted by peers who influence or force
their friends to abuse drugs so as to demonstrate status or superiority;
 Lack of follow-up care-in most cases patient get relapsed due to lack of follow-up
care to keep to their appo0itnment for review and constant check-up;
 Lack of support from relations/significant others: In some cases, patient do not get
enough care, concern and encouragement from their relations/significant others
and so they tend to lose confidence in themselves and these can lead to relapse;
 Lack of drug compliance – is one of the major cause of relapse as most patients
get tired of taking their medications as at when due;
  Existing disease conditions – some infection like HIV/AIDS tend to complicate
psychiatric condition as the body immune system is being destroyed in the
process of such disease condition.

2.1.4 Phases of Psychiatric Illness

The natural progression of psychiatric illness is usually described as deteriorating over

time. There is usually external plateau in the symptoms.

Only in some cases has it has been suggested that improvement might occur. In reality,
no one knows what the course of psychiatric illness would be if patients were able to
adhere to a treatment regime throughout their lives.

Only recently have their medications been relatively effective with manageable side
effects. At this point, it is understood that the symptoms of psychiatric illness combine in
various numbers and degree they differ from each other and the experience for a single
individual may be different from episode to episode, the typical course of the illness
appears to have phases.

i) Phase I: Initial Diagnosis and Early Psychiatric Illness

Here, the behavior may be both confusing and frightening to the patient and family. Often
the changes are subtle. However, at some point, the changes in thoughts and behavior
become so disruptive or bizarre that they can no longer be overlooked.

They might include episode of staying up all night for several nights. Incoherent
conservations, aggressive act against self and others, as the symptom progress, the patient
is less and less able to care for basic needs such as eating, sleeping and bathing. Usually,
the person may not be able to function at school or a job resulting in dependency on
family and friends. Because delusions and hallucinations seem so real, the individual is
generally unable to recognize the need for treatment. Usually Hospitalization or some
type of intensive outpatient treatment must be initiated by family and friends.
 ii) Phase II (Adaptation)

After the initial diagnosis of psychiatric illness and the successful initiation of treatment,
the patient enters a period in which symptoms may be less acute and require less drastic
measures to control. This however, is not a period of quiescence and the symptoms
actually become worse (Brere et al, 2019).

iii) Phase III (Relapse)

Relapse is a return of the illness symptom which are severe enough to disrupt daily
activities or require unscheduled inpatient or outpatient intervention (Murphy and Moller,
2021).

Relapse is not inevitable however, it occurs with sufficient regularity to be a major

concern in the treatment of psychiatric illness.

Reported relapse rates vary from 25% to 90% and relapse affects both those who are
being treated and those who are not. The lower relapse rate, is for the most part, among
groups who are following a treatment regimen.

2.1.5 Types of Relapse

1. Primary Relapse

This type of relapse occurs while the patient is in the hospital receiving treatment.
2. Secondary Relapse

In this type of relapse, the patient is discharged home but gradually relapses as a
result of some stressor around the environment.

3. Tertiary Relapse

This is where a patient breaks down after being discharged home and accepted in
the community where he belongs and eventually resumes his/her normal life and
responsibilities and is settled for some time but suddenly or gradually relapses due
to some conditions around him/her.
 4. Partial Relapse

This is type relapse where the patient breaks down in measure and not completely
and is still able to manage himself or herself to a certain extent.

5. Total Relapse

This is when the patient totally disintegrates mentally, socially and physically to
an extent that she/she cannot cope or manage him/herself and is completely
dependent on others for total care for activities of daily living and psychological
support to meet his needs and medical intervention.

2.1.6 Prevention of Relapse among Psychiatric Patients

i. Health Education:

It is very crucial and a part of a Nurse’s or Doctor’s responsibility to properly

health education the patients on the rules guiding hospital care both as in and
outpatients.

It is very vital for the patients to keep to appointment dates as it enhances

continuity of care and allows for assessment especially of eminent signs of
relapse. The patient is also instructed on drug compliance taking the drugs as at
when due and to report any hypersensitivity to drugs.

Proper information is given especially about his condition, to give the patient
insight to his condition and to alert him of factors that can precipitate a relapse.

If patient’s conditions are related to self-imposed stressor such as overwork,

unduly complicated social relationships, the patient should be encouraged to
change to a lifestyle less likely to lead to further episode of illness.

An alcoholic who works in a brewery might be asked to change occupation

ii. Also efforts should be made to detect early signs of relapse in patients in order to
issue prompt and adequate treatment, usually done in the outpatients units and
wards in general. It is also important to have in mind that efforts should be made
 to discharge the patients home as soon as he is well enough because prolonged
hospitalization precipitates relapse. Relatives should be encourage to visit client
regularly to make the patients have a sense of belonging and not to loose touch
with the family.

iii. While on admission, patients are given holistic and individualistic care. The
Nurses and other health care givers should establish a good rapport with the
patient creating a very conducive and therapeutic environment for recovery and
prevention of relapse. The social worker is informed to keep in touch with
relations of patients and to inform them when bills are due to be paid in the
hospitals. That will enhance the care given to patients.

There must be sufficient drugs and not only sufficient, the drugs must be proved
and useful and effective in the treatment of the condition. Other amenities in the
ward must be in place to keep the patient occupied and minds off the problem.

Examples of such are television or other indoor games.

iv. Family Oriented Therapies

Family oriented therapies are useful and helpful in treating psychiatric condition
because most times, patients are often discharged in an only partially remitted
state in parole.

Families to which a patient returns can often benefit from a brief but intensive
course of family therapy. The therapy should focus and the immediate solution
and should include identifying and avoiding potentially troublesome situations
(stressors).

Problems from within the family must also be resolved immediately.

After the immediate post discharge period, the recovery period, the recovery
process, its length and its rate are important subjects to cover in family therapy.
 Above all, patient’s family must accept him back as a member and learn to help
him reintegrate back into the family. The family must help the family to avoid
disability and redundancy.

v. Relapse Prevention Therapy (RPT)

This therapy is mostly used for drug dependents patients. It is a therapy that relies
on cognitive and behavioral techniques in addition to hospitalization on
outpatients basis to achieve the goal of abstinence.

The psychological intervention usually involves individuals, group and family

modalities. It also focuses on the future and on changes in the family activities.
They may help the patient stay off the drug. This approach can be used on a one
patient basis.

vi. Milieu Therapies and Rehabilitation

The general impression from experimental studies is that vigorous aggressive

outpatients after care programmes after discharge from the hospital combined
with drug treatments are effective in maintaining patients in the community and
wading off deterioration. Rehabilitation therefore starts from admission when the
patient develop in sight.

For either case, daycares are alternative to hospital care. The evidence for
inpatient activity programme is more circumscribed and less impressive. Their
main usefulness may come from possible prevention of institutionalization and
the secondary de-socializing and deteriorative effects of a barren environment and
form better discharge.

Employment planning and their effects on primary psychology may be relatively

small. In some chronic cases, push and intrusive interventions have been found to
aggravate symptoms. Therefore, these programmes should be regulated and
critically evaluated.
 Readmission rates are as high for chronic patients who have participated
intensively in hospital experimental programmes as they are for control patients
who have been involved in less innovative programmes. Evaluation of such
programmes leaves little doubt that they are useful in preventing relapse,
suggesting that treatment and support in the society precisely where the patient
needs help in adjusting in the appropriate direction or the future work with
chronic patients.

vii. Respite Care

It is a treatment approach designed to decrease the rate of relapse or exacerbation

of psychiatric symptoms and to afford families relief from their care given
responsibilities.

Respite care programmes (Greise, Honcho and King, 2015), provide mini
hospitalization for a few days every 6 – 8 weeks to reinforce patient’s growth and
to intervene in the early stages of relapse. Evidence suggests that overall time in
the hospital can be reduced with respite care.

viii. Follow up Care

This is essential for preventing relapse. The Patient and Nurse need to be aware
that recovery has began when an inpatient or outpatient programme is complete.
The few months immediately following completion of a treatment programme are
dangerous for the patient. This is when relapse is not uncommon. The Nurse
should confirm that arrangements for care and outpatient counseling are made
before discharge. There should be good following up care by the psychiatric
social workers to serve as a link between the relations of patient and the hospital..

viii. Mass Education

The awareness of mental illness should be made public through public
enlightenment regular seminars, radio programmes on the causes, prevention and
on misconception about mental illness.
ix. Government Involvement
 The government should active role in the care of the mentally ill. They should
subsidize the cost of drugs for the patient in order to ensure that all patient no
matter their social status should be able to afford their drugs. The government can
also through foreign aid import drugs and distribute to various psychiatric units
where they are given free to less privileged patients. All government hospitals
must have provision for psychiatric units render psychiatric services at the grass
root level. There should also be provision of employment opportunities for patient
soon after discharge in order to make them useful and a contributing member of
the society. To the frequency of re – hospitalizations client education about the
importance of the following medication regimes and abstaining from alcohol and
other substances have been shown to lengthen the time between hospitalizations.

2.2 Theoretical Framework

2.2.1 Cognitive Behavioral Chain
Pither (2016) looked at relapse process as a of the length sequences of the thought and
action. The behavioural chain generally consists of four distinct stages.
First there is life style, personality or situational event which firms the background to the
addictive behavior.
 The individual becomes dysphonic (experience negative mood state) as a result of
The stressor and consequently enter a high risk situation.
 The person lapses by thinking or fantasizing about the behaviour.
 The person relapses and commits the undesired actions. This theory explained that
relapse occurs in stages
2.2.2 Problem of Immediate Gratification (P.I.G)
Once the person is the high risk situation ten their anticipation of the pleasurable and
positive effect of the addictive behaviour create a situation of cognitive dissonance with
their desire to avoid the negative consequences. This is called problem of immediate
gratification and facilitate the chances of lapse occurring. This theory described that
when there is a problem with immediate gratification relapse can occur (G.ALAN
MARLATT 2017).
2.2.3 Abstinence Violation effect (A.V.E)
 Failure to deal adaptively with the high risk situation lead to decrease self-efficacy
relapse and the abstinence violation effect, essential awareness that the person
commitment to abstinence has been violated depending on how the abstinence violation
effect is manually managed, a relapse may or may not occur. This theory explain that
high risk situation leads to decrease self-efficacy relapse (Katie Witkiewitze 2014).

2.3 Conclusion
In conclusion, this chapter deals with the conceptual framework and theoretical
framework. It was reviewed that Barbara Scheon Johnson found out that non –
compliance with medications is commonly related to the frequency of re-hospitalization.
The trend in psychiatric care is studying from that of in – patient hospitalization to a focus of
outpatient care. This trend is needed due to it cost effectiveness in providing care to the masses
(town send 2018).