Community Psychiatry

Born in 1963, the community psychiatry movement has hailed as the third psychiatric revolution.

The first revolution was the age of enlightenment following the middle ages, when mental illness was viewed as a consequence of sin and witchcraft.

The second revolution was the development of psycho analysis which offered hope for a causative explanation of psychiatric disorders.

However, the community psychiatry movement was made possible by another revolution, the one ushered by the advent of psychopharmacology.

Therefore, it may be more appropriate to refer to community psychiatry as the fourth psychiatric revolution.

Generally, The period between 1955 and 1980 was an era of deinstitutionalization in USA and other Western countries, consisting of discharging mentally ill patients from mental hospitals, to be cared for in the community supported by community mental health centres.

Furthermore, This provided an impetus to the development of community psychiatry.

In 1975, the World Health Organization strongly recommended the delivery of mental health services through primary health care system as a policy for the developing countries.

In India, attempts to develop models of psychiatric services in the PHC (primary health centre) setting were made nearly simultaneously at PGI, Chandigarh in 1975 (especially, Raipur Rani block of Ambala district, Haryana) and NIMHANS, Bangalore in 1976 ( Sakalwara in Karnataka).

The basic model of community mental health was defined by Gerald Caplan in 1967.

The predominant characteristics of community psychiatry are i.e.:

• Responsibility to a population for mental health care delivery.
• Treatment close to the patient in community based centres.
• Provision of comprehensive services.
• Multi-disciplinary team approach.
• Providing continuity of care.
• Emphasis on prevention as well as treatment.
• Avoidance of unnecessary hospitalisation. [1]

National Mental Health Program (India):

Mental health is an integral component of health, which is defined as a positive state of well-being (physical, mental and social) and not merely an absence of illness.

With this aim in mind, an expert group was formed in 1980.

The final draft was submitted to the Central Council of Health and Family Welfare (the highest policy making body for health in the country) on 18-20 August 1982, which recommended its implementation.

The National Mental Health Programme (NMHP) appeared almost simultaneously with the National Health Policy (1993). [2]

Indian Mental Health Act (MHA)1987:

• This is the first Mental Health Act of free India.
• It has discarded the outdated concepts of custodial care and segregation of mental patients from the community.
• For the first time, it brings out judicial safeguards for patients’ rights.
• It has introduced humanitarian considerations to prevent indignity or cruelty to the mentally ill.
• It has simplified the procedures for admission and discharge of patients and it has tried to reduce the stigma attached to mental illness by bringing it at par with other physical illness.
• Thus the MHA 1987 is a definite positive contribution in the field of mental health. [4]

The objectives of NMHP are:

1. To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of population.
2. To encourage application of mental health knowledge in general health care and in social development.
3. Promote community participation in the mental health service development and to stimulate efforts towards self-help in the community. [1]

Responsibility to a population and community participation:

• Include the participation of the community regarding the mental health care needs and programmed.

Being closer to the patient:

• Mental health services should be provided to the patient at his home or place of work.

Continuity of care:

• A therapist/nurse following a given patient through emergency services, hospitalization and follow up in community.

Client-centered approach:

• Focuses on clients given attention to psychological problems to promotion of personal growth.

Avoidance of unnecessary hospitalization:

• Economical, avoids the stigma of being hospitalized in a mental hospital and avoids the regression which the mental hospital settings encourage.

Evaluation and research:

• Getting information about the usefulness and success of the program so as to modify and make new plans.

Prevention:

• To prevent the occurrence of mental illness. [2]

Three aims are specified in the NMHP in planning mental health services for the country:

1. Firstly, Prevention and treatment of mental and neurological disorders and their associated disabilities.
2. Secondly, Use of mental health technology to improve general health services.
3. Lastly, Application of mental health principles in total national development to improve quality of life.

Two strategies, complementary to each other, were planned for immediate action:

Center to periphery strategy:

• Establishment and strengthening of psychiatric units in all district hospitals, with outpatient clinics and mobile teams reaching the population for mental health services.

Periphery to center strategy:

• Training of an increasing number of different categories of health personnel in basic mental health skills, with primary emphasis towards the poor and the underprivileged, directly benefiting about 200 million people.

Services in Community Psychiatry:

The mental health care service was envisaged to include three components or subprograms, namely treatment, rehabilitation and prevention.

1. Treatment Subprogram:

Multiple levels were planned.

A. Village and sub center level:

Multi-purpose workers (MPW) and health supervisors (HS), under the supervision of medical officer (MO), to be trained for:

• Management of psychiatric emergencies.
• Administration and supervision of maintenance treatment for chronic psychiatric disorders.
• Diagnosis and management of grand mal epilepsy, especially in children.
• Liaison with local school teacher and parents regarding mental retardation and behaviour problems in children.
• Counselling in problems related to alcohol and drug abuse.

B. Primary health center (PHC):

MO, aided by HS, to be trained for:

• Supervision of MPW’s performance
• Elementary diagnosis
• Treatment of functional psychosis
• Treatment of uncomplicated cases of psychiatric disorders associated with physical diseases
• Management of uncomplicated psycho social problems
• Epidemiological surveillance of mental morbidity.

C. District hospital:

• It was recognized that there should be at least 1 psychiatrist attached to every district hospital as an integral part of the district health services.
• The district hospital should have 30-50 psychiatric beds.
• The psychiatrist in a district hospital was envisaged to devote only a part of his time in clinical care and greater part in training and supervision of non-specialist health workers.

D. Mental hospitals and teaching psychiatric units:

The major activities of these higher centres of psychiatric care include:

• Help in care of ‘difficult’ cases.
• Teaching.
• Specialised facilities such as occupational therapy units, psychotherapy, counselling and behaviour therapy.

2. Rehabilitation Sub Programme:

The components of this sub programme include maintenance treatment of epileptics and psychotics at the community levels and development of rehabilitation centres at both the district level and the higher referral centres.

3. Prevention Sub Programme:

• The prevention component to community-based, with the initial focus on prevention and control of alcohol-related problems.
• Later, problems such as addictions, juvenile delinquency and acute adjustment problems such as suicidal attempts are to be addressed.

The other approaches designed to achieve the objectives of the NMHP include:

• Integration of basic mental health care into general health services.
• Mental health training of general medical doctors and paramedical health workers.

A plan of action was outlined in 1982, with the first opportunity to develop it in the 7th five year plan starting from 1985, with a plan allocation of Rs. 100 lakhs (10 million).

A National Mental Health Advisory Group (NMHAG) was formed in August 1988 and a Mental Health Cell was opened in the Ministry of Health and Family Welfare under a Central Mental Health Authority (MHA).

Various activities were planned under the action plan for implementation of national mental health programme in the 7th five year plan, such as;

• Community mental health programs at primary health care level in states also union territories;
• Moreover, Training of existing PHC personnel for mental health care delivery;
• Development of a state level
• Mental Health Advisory Committee also state level program officer;
• Establishment of Regional Centers of community mental health;
• Formation of National Advisory Group on Mental Health;
• Development of task forces for mental hospitals and mental health education for undergraduate medical students;
• Involvement of voluntary agencies in mental health care;
• Identification of priority areas (child mental health, public mental health education additionally, drug dependence);
• Mental health training of at least 1 doctor at every district hospital during the next 5 years;
• Establishment of a department of psychiatry in all medical colleges and strengthening the existing ones;
• Provision of at least 3-4 essential psychotropic drugs in adequate quantity, at the PHC level.

The District Mental Health Programme (DMHP):

• It started in 1995 as a component of NMHP.
• The prototype of the this program was the Bellary District Program (in Karnataka, 320 km from Bangalore).
• Started in 1985, it caters to a population of 1.5 million.
• District hospital psychiatry units have opened in every district of Kerala also Tamil Nadu.

The revised National Health Policy (in other words, NHP-2002) has released in 2002.

Its focus on mental health “envisages a network of decentralized mental health services for ameliorating the more common categories of disorders”.

At the same time the NMHP 10th five year plan launched, with a plan to extend the DMHP to 100 districts.

It also emphasizes the need to broaden the scope of existing curriculum for undergraduate training in psychiatry and to give more exposure to psychiatry in undergraduate years and internship.

An essential list of psychotropic drugs was also prepare.

The emphasis of NMHP-1982 was primarily on the rural sector.

It being realized that the urban mental health needs also need to address under the ambit of NMHP.

During the 11th five year plan, an allocation of Rs 1000 crore (Rs 10 billion) has been made for the NMHP.

The current focus (2009) is on;

• Establishing centers of excellence in mental health,
• Increasing intake capacity also starting postgraduate courses in psychiatry,
• Modernization of mental hospitals,
• Upgradation of medical college psychiatry departments,
• Focus on non-government organizations (in other words, NGOs),
• Public sector partnerships,
• Media campaign to address stigma,
• A focus on research and
• Several other measures. [1]

The community mental health team:

The community mental health team should i.e.:

• Psychiatrist,
• Clinical psychologist,
• Psychiatric social worker,
• Psychiatric nurse,
• Occupational therapist

Other administrative staff to provide service i.e.;

• Hospitalization,
• Follow up,
• Residential services,
• Consultation and education.

Psychiatrist:

• Medical doctor with special training in mental illness also behavioral/emotional problems.
• Diagnoses conditions also prescribes medical treatment. [2]
• The clinical leader of the team and responsible for psychiatric assessments.
• Initiates and supervises drug treatments also provides brief psychological interventions.
• Supervises outpatients, inpatients, also day patients. [3]

Clinical psychologist:

• In brief, Provides individual and group therapy.
• Performs psychiatric testing. [2]
• Performs psychological assessments and provides a full range of psychological treatments. [3]

Occupational Therapist:

• Provides individual therapy.
• Conducts group therapy sessions. [2]
• Performs functional assessments, provides social skills training, some psychological treatments, and assists the patient in finding employment. [3]

Social worker:

• Community resource education.
• Discharge planning. [2]
• Performs social and mental health act assessments and assists the patient in meeting accommodation and financial needs.
• May also provide some psychological treatments. [3]

Recreation therapist:

• Incorporates leisure activities in group settings to demonstrate healthy coping mechanisms. [2]

Nurse:

• Administers medications.
• Conducts group education sessions.
• Provides patient support and directs care. [2]
• The core members of the team who usually work exclusively in the CMHT.
• Act as key workers for patients with chronic mental disorders, monitor medication and side effects, and provide some psychological treatments. [3]

Psychiatric technician

Assists nursing staff:

Provides support to client. [2]

Advantages of psychiatric movement:

Shorten length of inpatient Stay:

• After management of the acute problem, many patients can be transferred to a suitably structured residential alternative for an additional stay, thus shortening the duration of in-patient stay.

Transition from hospital to community:

• A short stay in a suitable community residence will help longinstitutionalized patients in regaining the skills and capacities required to cope with everyday situations.

Respite care:

• Many psychiatric patients remain with or leave the hospital to live with immediate families or relatives.
• Temporary placement in a community residence may provide a period of relief from stress for both patient and family and assist in the maintenance of the patient’s reintegration within the family.

Cost effective:

• Many studies have proved that community care of psychiatric patients is much more economical than care in hospitals.

More effective:

• Community care improves clinician’s assessment of the problems that patients have while living
  in the community.
• It also increases the therapeutic impact of clinical interviews.

Easy Accessibility:

• With availability of services at periphery, more people avail of the facilities.
• The integration of mental health care with PHC system is a major innovation towards this.
• In our country, especially, where 80% of the people live in rural areas constrained by forces of terrain and weather, and hampered by limitations of money and time, easy accessibility is of vital importance for increased utilization.
• The experiences of Raipur Rani and Sakalawara make this amply clear.

Increased Acceptance:

• In brief, With the advent of community psychiatry, attitudes of the people have changed towards greater acceptance of the mentally ill.

Better Rehabilitation:

• Rehabilitation and acquiring of social skills by patients who have partially or fully recovered from mental illness, is much better in a community set-up than in any mental hospital.

Multidisciplinary Therapy:

• Realization of multidisciplinary therapy is more practical and better in a community set-up.

Close connection with different medical disciplines:

• In the community set-up psychiatric care can establish close connection with other medical disciplines for better global management of patients.

Family involvement:

• In community care of patients, family involvement is better as the patient is not separated from the family.
• The family members also undergo a learning experience and modify their behaviour.
• It also serves as a focus for mental health education.
• Finally I would like to comment that for any effective community oriented program, 4 points are important:
  • Political or planners’ commitment
  • Professional commitment
  • Progress in mental health know-how
  • Participation of the Community. [4]

Limitations of psychiatric movements:

Re institutionalisation: “Revolving door syndrome”

• In the U.S. when deinstitutionalization and non institutionalization were being implemented rather vigorously, the fall in the number of in-patients was associated with recurrent short admissions a sort of revolving door pattern was noticed.

Shortage of funds:

• At least in the initial stages, community psychiatry needs enough funds.
• As in other countries, in India also shortage of funds hampers proper community care and rehabilitation services.

Manpower Problems:

• The mis distribution of psychiatric manpower continues to be a major limitation.
• There are an insufficient number of psychiatrists in public clinical and administrative roles, for both state hospitals and community psychiatric care.

Social determinants:

• Attitudes towards the mentally ill still reflect an extraordinary degree of social stigma.
• Whether it derives from a frozen belief in the superiority of inpatient treatment or from the wish to protect the community, there is a powerful social attitudinal pressure opposing alternatives to hospitalization.
• An idealized vision of community psychiatry can place upon the lives of other household members, friends and the society as a whole, a burden, which they may find too heavy.
• It then leads inevitably to negative attitudes and rejection of patients. [4]

Geographical factors:

• Poor coverage of rural areas, distance, the need to travel and time constraint. [2]

Criteria for hospitalization of a mentally ill patient:

In order to be considered eligible for admission to an acute inpatient psychiatric unit, an individual must meet one or more of the following criteria:

• The patient is an imminent threat to himself/herself.
• The patient poses an imminent threat to the safety and/or well-being of others.
• Patient is unable to provide for his/her basic needs in spite of having adequate resources.
• Patient is out of control. [2]

1. Voluntary Hospitalization:

• Admission process similar to medical hospitalization, Mean the patients are willing to seek treatment and agree to be hospitalized.
• Patient may stay as long as treatment deemed necessary.
• Patient have the right to leave at any time.
• Patients have right to demand also obtain release.
• Many states require patient submit written release notice to staff.

2. Involuntary Hospitalization:

• Client is hospitalized without consent, the patient does not wish to hospitalized also treated.
• Situation must considered an emergency.
• Client receives observation also treatment for mental illness.

An individual can be involuntary admitted;

• When the client is danger to themselves or others, attempted suicide or represent a danger to others.
• Inability to provide for basic human needs, including food, clothing, shelter, essential medical care, or personal safety.
• Necessary when person is danger to self or others, unable to meet basic needs as result of psychiatric condition.

Emergency involuntary hospitalization i.e.:

• Commitment for specified period (1-10 days) to prevent dangerous behavior to self/others.

Observational or temporary involuntary hospitalization i.e.:

• Longer duration than emergency commitment.
• Purpose: observation, diagnosis, also treatment for mental illness for patients posing danger to self/others.

Release from the hospital i.e.:

• Voluntary admitted client have the right to leave, provided they do not represent a danger to themselves or others.
• They can sign a written request for discharged also can be released from the hospital. [2]

Frequently Asked Questions

What is Community Psychiatry?

Community psychiatry can be defined as the provision of psychiatric services to the patient within their community environment with an aim to achieve full social integration.

Give benefits of Psychiatry movement?

• Shorten length of inpatient Stay
• Transition from hospital to community
• Respite care
• Cost effective
• More effective
• Easy Accessibility
• Increased Acceptance

What are the aims of National Mental Health Programme?

1. Firstly, Prevention and treatment of mental and neurological disorders and their associated disabilities.
2. Secondly, Use of mental health technology to improve general health services.
3. Lastly, Application of mental health principles in total national development to improve quality of life.

What are the objectives of National Mental Health Programme?

1. Availability and accessibility of minimum mental health care for all
2. To encourage application of mental health knowledge in general health care
3. Promote community participation in the mental health service development and to stimulate efforts towards self-help in the community.