Community Psychiatry

Overview of Community Psychiatry

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

First 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.

Second Revolution

The second revolution was the development of psychoanalysis 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]

Team

The community mental health team:

• 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 people who are 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 people who are 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]

Hospitalization Criteria 

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]

Types Of Admission 

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]

Terminology 

References of Community Psychiatry

1. A Short Textbook of Psychiatry 7th edition by Niraj Ahuja / Ch 21.
2. http://www.uobabylon.edu.iq/eprints/publication_10_16484_241.pdf
3. Psychiatry, Fourth Edition – Oxford Medical Publications -SRG-by John Geddes, Jonathan Price, Rebecca McKnight / Ch 11.

4. Community Mental Health: A Practical Guide (4th Edition), Author: Graham Thornicroft, Tom Burns (2001), Publisher: Oxford University Press

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