Community Psychiatry

What is Community Psychiatry

• “The branch of psychiatry concerned with the development of an adequate and coordinated program of mental health care for residents of specified catchment areas.”

Community Care

• Provision of comprehensive mental health services for a well-defined catchment area, demarcated geographically and administratively, such as a borough, district, or county (Farooq and Minhas, 2001).
• In our own context, this will include a state, local government area, ward, etc.
• Simply means providing mental health services to persons and families with mental illness within the community using community resources.
• A whole system of care in which the patient's community, not a specific facility such as a hospital, is the provider of care for people with a mental illness.
• The aim is to achieve full integration.

• Responsibility to a population
• Community participation
• Mental health service is close to the patient's home
• Multi-disciplinary team approach
• Continuity of care
• Consumer participation
• Client-centered approach: attention to psychological problems to promotion of personal growth
• Comprehensive services
• Avoids unnecessary hospitalizations

(Caplan and Caplan, 1967)

CMHC (Community Mental Health Center)

Comprising the principles and practices needed to promote mental health for a local population by:

• Addressing population needs in ways that are accessible and acceptable
• Building on the goals and strengths of the people who experience mental illnesses
• Promoting a wide network of support services and resources of adequate capacity
• Emphasizing services that are both evidence-based and recovery-oriented

(Thornicroft et al., 2011)

• Mental illness is a major contributor to the Global Burden of Disease.
• Mental illness accounts for 12% of the disease burden of the world.
• Mental illness is an increasing problem in prevalence and severity.
• The percentage of Disability Adjusted Life Years (DALYs) from mental illness is increasing:
  • In 1990 - 10% of all DALYs
  • In 2000 - 12% of all DALYs
  • In 2020 - 15% of all DALYs
• Mental illness can be treated effectively.
• Mental illness can be prevented.
• Mental illness accounts for 1 in 6 years lived with disability.
• People with severe mental illness die 10-20 years earlier than the general population.

Community Response to Mental Illness

• Most communities respond negatively to people with mental illness.
• This is due to their perceptions and beliefs about mental illness.
• Further leading to stigma and discrimination of people with mental illness.

Barriers to Mental Health Care Treatment

• Stigma
• Lack of Mental Health Literacy
• Lack of manpower
• Uneven distribution of resources
• Poverty
• Poor access to care
• Financial factors (cost of travel, lost wages)
• Programmed factors (fragmented services, poor priority settings)

• Mental health promotion
• Stigma removal
• Psychosocial support
• Rehabilitative services
• Prevention of harm from alcohol and substance use
• Treatment of illnesses using Primary Health Care within communities
• Residential care
• Community services
• Crisis intervention
• Treatment
• Housing services
• Outpatient services
• Case management
• Counselors
• Emotional support

The Community Mental Health Team

• Psychiatrist
• Clinical psychologist
• Psychiatric social worker
• Psychiatric nurse
• Occupational therapist
• Other administrative staff
• Peer specialists/recovery coaches

Models of Community Care

• Conceptual models:
• Hive system:
  • The hospital as the center of activities with various facilities such as day hospitals, clinics in the community.
  • Advantages include easier administrative system and a good range of professional expertise and beds.
  • Disadvantages include poor accessibility for many patients, delayed referral, poor knowledge of community structure, and concentration of resources in the hospital.
• Network system:
  • Comprises a network of community resources of which the hospital is only one of them.
  • The core of the service is a community-based multidisciplinary team.

• The morbidity burden is great.
• Mental and physical health problems are interwoven.
• The treatment gap is enormous.
• PHC care for mental health:
• Enhances success.
• Promotes respect for human rights.
• Is affordable and cost-effective.
• Narrows the treatment gap.
• Generates desirable health outcomes.

Main Strategies

• Developing policy to incorporate mental health care into PHC.
• Advocacy to improve attitudes and behavior regarding mental health care.
• Training of PHC workers in screening for mental disorders.
• Availing specialists and facilities readily available to support PHC physicians.
• Access of PHC physicians to essential psychotropic medications.
• Presence of a mental health-service coordinator in PHC clinics.
• Collaboration with other government non-health sectors, non-governmental organizations, village and community health workers, and volunteers.
• Adequate funding for necessary staff and mental health specialists.

• Mental health services in Nigeria (Calabar, 1904 & Yaba, 1907)
• The therapeutic phase (1954 to date)
• Psychiatric Hospitals
• Psychiatric departments in Teaching Hospitals
• General Hospitals and Federal Medical Centres; Private services
• Community Psychiatric Services** (Are the criteria met???)
• Integration into Primary Health Care (PHC)

THE ‘ARO VILLAGE’ System

• Dr. Lambo introduced the innovative village system of managing psychiatric patients in 1956.
• Through negotiations, patients were admitted to nearby villages with their accompanying relatives, and daytime nursing care was provided by nurses in these rented apartments for the duration of their treatment.
• Borrofka and Olatawura (1977) reported that, over a period of 50 months, 512 psychiatric patients were treated in the Aro Village therapeutic community.
• The majority of those admitted (94.1%) had symptoms of psychosis, with 57.8% discharged by the end of 3 months, and 88.9% by the end of five months. Of these, 70.3% were judged fit to return to their work.
• The relatives of patients as well as the villagers were involved in the treatment program.

Mental Health Service in Nigeria - Summary

• The bulk of psychiatric services are provided by the 12 (7 federal and 5 states) regional psychiatric hospitals and the departments of psychiatry in 12 medical schools.
• A number of private hospitals, general hospitals, and federal medical centers now provide psychiatric services.
• Evolving Community Mental Health services/programs of state governments and NGOs, e.g., CBM.
• These services are not well-coordinated and are mainly institution-based, with service utilization by community samples of people with disorders less than 10% (Gureje 2006).
• Despite these facilities, mental health care remains inadequate, with the ratio of psychiatric beds being about 0.4 to 10,000 persons (WHO 2001).
• Evolving Primary Care Mental Health programs.

It was defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management, or prevention’. Indeed, mental health literacy is composed of several components, including:

1. The ability to recognize specific disorders or types of psychological distress.
2. Knowledge and beliefs about risk factors and causes.
3. Knowledge and beliefs about self-help interventions.
4. Knowledge and beliefs about professional help available.
5. Attitudes which facilitate recognition and appropriate help-seeking.
6. Knowledge of how to seek mental health information.

Mental health literacy has been defined to include:

• Understanding how to obtain and maintain positive mental health.
• Understanding mental disorders and their treatments.
• Decreasing stigma related to mental disorders.
• Enhancing help-seeking efficacy (knowing when and where to seek help and developing competencies designed to improve one’s mental health care and self-management capabilities).

Clinical Implications of Mental Health Literacy

• The public does not share many of the core beliefs of clinicians regarding the treatment and etiology of mental disorders.
• Clinicians may have difficulty implementing evidence-based mental health care if patients do not believe in the interventions offered.
• An increase in mental health literacy in the population may assist prevention, early intervention, effective self-help, and support of others in the community.
• Enhanced understanding of mental health literacy (MHL) and the development of contextually and developmentally appropriate interventions, which are independently evaluated using validated measurements, may be expected to help achieve improvements in both individual and population mental health outcomes in the future.

• Developed to promote the human rights of persons with mental disorders and to reduce stigma and discrimination.
• Consists of actions aimed at changing the structural and attitudinal barriers (stigma) to achieving positive mental health outcomes in populations.
• Addresses issues such as stigma and discrimination by promoting education and awareness about mental health conditions.
• Works towards addressing policy changes that improve access to mental health services and supporting individuals who are affected by mental health challenges.
• Advocacy is considered to be one of the key areas for action in any mental health policy because of the benefits that it produces for people with mental disorders and their families (World Health Organization).

ADVOCACY: Principal Elements

1. Advocacy actions
2. Awareness-raising
3. Information
4. Education
5. Training
6. Mutual help
7. Counseling
8. Mediating
9. Defending
10. Denouncing

Advocacy is an important means of raising awareness on mental health issues and ensuring that mental health is on the national agenda of governments. Advocacy can lead to improvements in policy, legislation, and service development.

Who Are Those Involved in Advocacy?

• Patients and families
• Patients have played various roles in advocacy, ranging from influencing policies and legislation to providing concrete help for persons with mental disorders. The provision of care for persons with mental disorders is a distinctive role for families, particularly in developing countries.
• In many places, they are the primary care providers and their organizations are fundamental as support networks.
• In addition to providing mutual support and services, many family groups have become advocates, educating the community, increasing the support obtained from policy-makers, denouncing stigma and discrimination, and fighting for improved services.

Participation in advocacy organizations by patients and families has several positive outcomes:

• Improvements in the policies and practices of governments and institutions, changes in laws and government regulations.
• Improvements in the promotion of mental health and the prevention of mental disorders, protection and promotion of the rights and interests of persons with mental disorders and their families, and improvements in mental health services, treatment, and care among others.
• Nongovernmental Organizations (NGOs)

Nongovernmental organizations involving mental health professionals or people from diverse fields fulfill many of the advocacy roles described for patients and families. Their distinctive contribution to the advocacy movement is that they support and empower patients and families.

Examples of such organizations include:

• SURPIN
• MANI
• MIND READERS ACADEMY
• MINDFULLY YOURS
• ASIDO FOUNDATION
• Mental Health Workers
• Mental health workers and general health workers have taken a more active role in protecting patients’ rights and raising awareness for improved services, especially as care has been shifted from psychiatric hospitals to community services.
• Some specific advocacy roles for mental health workers relate to:
• Clinical work from a patient and family perspective
• Planning and participation in the activities of patients and family groups
• Policy-makers and Planners
• Policy-makers and planners in the ministries of health play an important role in advocacy, either by:
• Direct actions to influence the mental health of populations
• Working indirectly through supporting advocacy groups (patients, families, nongovernmental organizations, mental health workers)
• Convincing other policy-makers and planners, such as:
• The executive branch of government
• The ministry of finance and other ministries
• The judiciary
• The legislature and political parties
• To focus on and invest in mental health.

Proposed Advocacy Plans

• Making brief documents identifying the priority areas in mental health.
• Identifying one or two psychiatric services with the best practices in the country and negotiating a joint demonstration project. This should involve the ministry of health and the psychiatric services. It should have the goal of forming consumer groups and/or family groups with advocacy functions. Technical support and funding are necessary.
• Identify and collaborate with one or two stakeholder groups interested in the rights of people with mental disorders.
• Empower the advocacy groups by providing them with information, training, and funding, focusing on consumer organizations.
• Collaborate with government agencies for formulating the plans.
• Conduct campaigns, for example, using radio and leaflets, to inform the population about the advocacy group.

• Greek word meaning ‘mark’ and originally referred to a sign branded onto criminals or traitors in order to identify them publicly. (Oxford Unabridged Dictionary).
• The process by which the reaction of others spoils normal identity. (Erving Goffman, 1963).
• A stamp, label, or mark that sets a person apart from others, connects the person to undesirable factors, and leads to rejecting the person. (Ottman et al., 2001).
• Stigma is a strong barrier to the reintegration of psychiatric patients into society/community (Vezzoli et al., 2001).

Described on three conceptual levels:

• Cognitive,
• Emotional, and
• Behavioral,

which allows us to separate mere stereotypes from prejudice and discrimination.

STEREOTYPES

• Perceptions, beliefs, and expectations a person has about members of a particular group.
• Prominent stereotypes surrounding the mentally ill presume dangerousness, unpredictability, and unreliability.

PREJUDICE

A negative attitude toward an individual or entire category of people based simply on identifying with a particular group.

DISCRIMINATION

Negative differential treatment of individuals who belong to a different group, or are perceived as different, or a minority group.

STIGMA: Types

• Public/Social stigma: Involves the negative or discriminatory attitudes that others have about mental illness.
• Self-stigma: Refers to the negative attitudes, including internalized shame, that people with mental illness have about their own condition.
• Institutional/Systemic stigma: Involves policies of government and private organizations that intentionally or unintentionally limit opportunities for people with mental illness. Examples include lower funding for mental illness research or fewer mental health services relative to other health care.
• Experienced stigma: Refers to the actual encounter with stigmatizing attitudes and behavior from the general population.
• Anticipatory/Perceived stigma: Refers to the beliefs and expectations that people with mental illness have about the general population's stigmatizing attitudes toward themselves.
• Professional stigma/healthcare stigma: Occurs in any healthcare setting where a patient is judged based on their mental health condition for unrelated causes.
• Double stigma: Two highly stigmatized conditions sensitive to cultural themes occur in the same individual. Example: schizophrenia and epilepsy.
• Stigma by association/courtesy stigma: Involves public disapproval evoked as a consequence of associating with stigmatized persons.

CONSEQUENCES OF STIGMA

This can be further discussed using the biopsychosocial approach.

• Biological
• Psychological
• Sociological

Biological

• Worsening of other pre-existing conditions.
• Double morbidity.
• Mortality.

Psychosocial Causes

• Reduced hope.
• Lower self-esteem.
• Increased psychiatric symptoms.
• Difficulties with social relationships.
• Reduced likelihood of staying with treatment.
• More difficulties at work.
• Reluctance to seek help or treatment and less likely to stay with treatment.
• Social isolation/Exclusion.
• Lack of understanding by family, friends, coworkers, or others.
• Fewer opportunities for work, school, or social activities or trouble finding housing.
• Human rights violation (Bullying, physical violence, or harassment).
• Health insurance that doesn't adequately cover treatment for mental illnesses.
• The belief that a person with mental illness will never succeed at certain challenges or can't improve their situation.

Steps in Curtailing Stigma

Approaches to changing stigma have been divided into three paradigms (Corrigan et al., 2012):

• Education
• Contact
• Protest

Education

Educational approaches to stigma challenge inaccurate stereotypes about mental illnesses, replacing them with factual information.

Examples include public service announcements, books, flyers, movies, videos, web pages, podcasts, virtual reality, and other audiovisual aids.

Contact

• Individuals of the general population who meet and interact with people with mental illnesses are likely to lessen their levels of prejudice.
• It must be targeted and continuous. Employers, landlords, healthcare providers, legislators, and media outlets.

Protest

• Protest/social activism highlights the injustices of various forms of stigma and chastises offenders for their stereotypes and discrimination.

Build an Instinct Toward Person-First Language

• Telemedicine is defined as the intervention of a telecommunication device in diagnosis, treatment, and overall care of patients that are separated from healthcare providers by distance. It is also used in research and evaluation.
• Telepsychiatry includes the provision of a range of services like evaluations, therapy, patient education, medical management, etc.
• Synchronous (mimic face to face) or asynchronous (store and forward).
• Methods include telephone calls, text messages, two-way closed-circuit TV, email, online chat, video conferencing, website and blogs, and virtual chat rooms.

Advantages

• Improves access to care.
• Improves quality of care.
• Encourages continuity of care.
• Cost-efficient.
• Convenient.
• Helps those marginalized.
• Better reach to remote areas.
• Reduces stigma.

Disadvantages

• Need for secure technological support.
• Lack of intimate contact.
• Ethical issues.
• Legal issues.

The Important Ps (Capturing Relevant Client Info)

• Pertinent history
• Predisposing factors
• Precipitating factors
• Perpetuating factors
• Present condition
• Previous treatment and response
• Prioritization
• Preferences
• Prognosis
• Possibilities
• Protective factors