CHANGINGFOCUSOFCAREINCOMMUNITYMENTAL HEALTH INTRODUCTION:
CommunityMentalhealthiaanidea,aphilosophy,anenactment that came to
reality in 1963 with the late American President John F. Kennedys
Bold
NewApproach.Thecommunitymentalhealthmovementrepresentsthefourth
revolution in Psychiatry. In 1841, Dorothea Dix appointed herself
inspector of institution for the mentally ill and began crusading
for more humane treatment. She wanted each
stateassumeresponsibilityforitsmentallyill.Theresultwastheestablishmentof32
mentalhospitalsintheUnitedStates.Mostmentalhospitalswerebuiltinruralareas,
whichofferedinexpensiveland,theremovaloftroublesomepeoplefromthe
mainstream of society and fresh air and quietness for the patients,
thus the concept of community mental health came into practice.
DEFINITION OF COMMUNITY MENTAL HEALTH
Communitymentalhealthdescribesachangeinfocusofpsychiatric
mentalhealthcarefromtheindividualtotheindividualininteractionwithhis
environment, care is provided to client outside of hospitals, in
the least restrictive setting and it is provided at home or as
close as possible to where the client lives. Community mental
health services are designed to provide comprehensive, continuous
care to populations of people who need themand it should be
available to
all,regardlessofpersonalcharacteristicssuchasage,abilitytopay,orplaceof
residence.Theycouldbetreatedinfreestandingcommunitymentalhealthcentres,in
treatment units of general hospitals and in translational homes.
-Dr.K.Lalitha HISTORICAL DEVELOPMENT OF COMMUNITY MENTAL HEALTH
Thecommunitymentalhealthcareservicesstartedwithanaimofproviding
mental health treatment in the community and thus to greatly reduce
the census
oflargepublicpsychiatrichospitalslocatedatadistancefromthehomesand
families of patients.
Initiallyitwasdesignedtoprovidefivebasicservices:outpatient,partial
hospitalization, inpatient, emergency and consultation and
education Subsequently it extended its service to children and
geriatrics
Thecommunitymentalhealthprogramcreatedacommunitybasedsystemof
mental health careA wide range of mental health services became
available in communities.
Innovativeserviceslikementalhealthconsultationtoschools,geriatrichomes,
and in day care centres. The census of psychiatric hospitals
decreased dramatically and the presence of mentally ill in the
community decreased the stigma about mental illness
In1975,theWorldHealthOrganizationstronglyrecommendedthedeliveryof
mentalhealthservicesthroughPrimaryHealthsystemasapolicyforthe
developing countries.
InIndia,beforeIndependence,therewerenoclearplansforthecareofthe
mentallyillpatients.Theapproachwaslargelytobuildasylumswhichwere
custodial rather than therapeutic
In1946,Bhorecommitteerecommendedtoincreasemanpowerinthefieldof
mental health.
In1962,theMudaliarcommitteeenvisagedpsychiatricservicesatalldistrict
hospitals. Later in 1975, an attempt wasmade by PGI, Chandigarh to
develop a model of
psychiatricservicesinthePHC,RaipurRaniBlockofAmbalaDistrict,and
Haryana, and in 1976, by NIMHANS, Bangalore at Sakalwara in
Karnataka. Thus the approach to development of services has been a
rapid transition from mental
hospitalstopsychiatricunitsofgeneralhospitalsand
tocommunitycare.The impetus for this approach has come from the
following sources: The commitment of the country to provide health
services to all The Alma Atta Declaration of Primary health care
The existence of a large infrastructure of general health services
(PHC system)
Therealizationofthemagnitudeofseverementaldisordersintherural
community (at least 1%) is as same as in the urban community and
availability of simple interventions for these conditions
ThesuccessfulexperienceofcommunitymentalhealthcareofBangaloreand
Chandigarh. DEVELOPMENT OF COMMUNITY MENTAL HEALTH SERVICES IN
INDIA yThe institutional treatment for mental disorders in India
and the use of allopathic medicine were introduced by the European
rulers.
yCharakaandotherspracticedindigenousmedicalsystemsconsideredmental
disorders to be asadhya (unmanageable)
yThustheirtreatmentwaslefttofolkhealers,whopracticedtheirartinthe
community setting.yIn 1970s survey (Kapur) of mental disorders in a
South Karnataka district, 75% of those suffering from severe mental
illness were still being taken for treatment to the traditional
folk healers
yTherewere26traditionalhealersforapopulationof10,000whichisafair
therapist patient ratio by any standard,
INSPIRATIONFORTHECOMMUNITYMENTALHEALTHMOVEMENTININDIA COMES FROM
THREE SOURCES oThe treatment of mentally ill patients for long
period in mental hospitals results in social breakdown syndrome.
Kennedy administration launched American version of the community
mental health program.
oInstitutionbasedpsychiatrycarethroughtrainedprofessionalscanbevery
expensive and country like India cannot afford to prepare
sufficient manpower
oThecontributionofpara-professionalsandnonprofessionalswithsimpleand
short training delivered reasonably adequate mental health care.
CRITICAL ACCOUNT OF THE MENTAL HEALTH SERVICES IN INDIA
1.Inthelate1950sDr.Vidyasagarbegantoinvolvefamilymembersinthe
treatmentofmentallyillpatientswhowereadmittedtotheAmritsarmental
Hospital. This approach -Reduced the hostility in the minds of the
patients for having been abandoned in a strange place
-Helpedtoremovetheage-oldmythsabouttheincurabilityofmentalillness
when the family began to see the patient recovering -The relatives
are made to learn the essential principles of mental health care
and were thus motivated towards imprisonment in their own ways of
life. Thus
manypatientsactuallywentbackwiththeirfamiliesandthedischarge
statistics began to rise. 2.Psychiatric Units in General Hospitals
-1933- the GHPUs was set up at R.G Kar Medical college at Kolkatta
-1960- many GHPUs came up because of the availability of
anti-psychotics . 3.The NIMHANS Crash Progrmme
-TheDirectorDr.R.M.VarmaandDr.KaranSingh,Ministerofhealthinthe
CentralGovernment,jointlyintroducedcommunitybasedmentalhealth
program at NIMHANS -In October, 1975, a community Psychiatry Unit
(CPU) was started. It initiated the following activities
#Primaryhealthcentrebasedruralmentalhealthprogramme:Amanualwas
prepared to train the multipurpose health workers to recognize
cases of severe mental
illnessandfollowthemundertheleadershipofthePHCdoctor.Anothermanualwas
preparedtotrainthedoctorstodiagnosecasesofseverementaldisordersandtreat
them #Generalpractitionerbasedurbanmentalhealthprogramme:amanualwas
prepared to teach GP methods of treating common mental disorders
#Schoolmentalhealthprogram:schoolteachersweretrainedtodiagnose
children with emotional problems and treat them # Home based follow
up of Psychiatric patients: nurses were trained to follow up
patients in their homes through monthly visits # Psychiatric camps
were organized: village leaders were involved in therapeutic
process and that helped to reduce the stigma against mental
patients. Ruralmentalhealthprogramwasstartedatahealthcentreinthe
villageofsakalwara,nearBangalore.Itconducted15daystrainingprogramtoPHC
personnel on regular basis and they carried out the follow up
services in the absence of supervision by professionals. 4.The
Chandigarh Experiment
-AruralmentalhealthprogrammewasstartedinthePGIMER,Chandigarh
withthehelpofWHO.ManualsweredevelopedandtrainingforthePHC personnel
were started and they carried out their work without the
supervision of professionals 5.ICMR- DST study on severe mental
mortality: Bangalore, Vadodara, Patiala and Kolkata centres were
chosen to study the impact of training of MPHWs and Gps in
detecting and treating mental patients
6.TheNationalMentalHealthprogramme(1982)waslaunchedtoensurethe
availabilityandaccessibilityofminimummentalhealthcareforallinthe
foreseeable future
7.TheDistrictMentalHealthProgrammewaslaunchedasapilotmodel
programme in the Bellary District by NIMHANS in 1980s 8.The
national workshops on mental health care for the state health
administrators
heldatNIMHANSin1996andtheworkshoptoreviewtheDMHPinOctober 2000 and
by then DMHP model has been adopted by many states. 9.Chatterjee et
al conducted a study writing a 3-tier model for the delivery of
mental health services at Barwani. -The first tier was the
outpatient program -The second tier employed mental health workers
drawn from local community -The third tier consisted of family
members and key people in the community 10.
Involvementoflayvolunteerstocounselthementallysick.Ashortperiodof
training is given to them 11.
Manyindustrialorganizationsprovidedpersonality-enhancementprogramsfor
their employees 12. Role of folk-healing, spiritual and religious
counseling and ancient techniques like yoga are still continuing to
help the mentally distressed. ALTERNATIVES TO INSTITUTIONAL CARE:
NIMHANS,Bangaloreandotherinstitutionshavedevelopedother
alternatives to institutional care Extensive use of outdoor
services: Family members are encouraged to treat their
patientsathomeandgetdrugsandsuggestionsfromthehospitalbyperiodic
regularvisits.Alltypesoftreatment,includingECT,aregivenintheoutpatient
setups.Shortstaywards(forfewhoursto48hours)facilityisorganizedinout
patient building, so that acute problems are managed and the
patient is discharged. Extension Programs by Satellite clinics:
Mental health team conducts a weekly or
monthlyclinicattalukordistrictheadquarters.Thelocalmedicalandnon-governmental
voluntary organizations are motivated to be the local hosts and
help in
patientcare.Suchsatelliteclinicsarefunctioningsuccessfullyin6centresof
Karnataka and few centres in other parts of the country.
Domiciliary care program: a mental health professional or a
visiting nurse delivers
therequiredservicestothepatientsattheirdoorsteps.Inastudy,theurban
schizophrenicpatientsweretreatedathomeandfollowedupfor6months.
Compared to the hospitalized patients, the home groupconsistently
did better both in clinical state and social functioning.
OrganizingcarethroughprivategeneralPractitioners:shorttermcoursesare
arrangedtoimprovetheknowledgeandskillsofprivategeneralpractitionersin
managingpsychiatricproblemsseenintheirroutinepractice.Theyareeasily
acceptedbypeopleanddeliveredgoodcarefortheneedy.Theyhavetobe
supportedbymentalhealthprofessionals,bybeingavailableforconsultationin
managing difficult cases. Training school teachers in mental health
care and promotion of mental health
throughschools:Trainingprogramsareorganizedintwophasesforschool
teachersinrecognizingandmanagingpsychosocialproblemsofstudentsthrough
counseling. The experience so far indicates that it is possible to
sensitize teachers in
recognizingandinterveningwhenfacedwithproblemspertainingtomentalhealth.
This approach towards the problem Children changes for the better.
Involvement of ICDS personnel in Child mental health care:
Anganwadi workers are trained in basic mental health care, so that
they identify and refer children with mental retardation and
behavioral problems to medical institutions and later manage them.
They would also improve the child-rearing practices of parents to
improve the psychosocial development of children.
Traininglayvolunteers:Interestedandcommittednaturalhelpersinthe
communityaregiven40sessionsoftrainingincounseling,sothattheycanhelp
individuals who are in distress because of psychosocial problems.
They have to be supervised and monitored by mental health
professionals. In voluntary sector, there
areseveralcounselingcentresofferingservicestopeoplewithmaritaldiscord,
peoplewithproblemchildren,peoplewhoarehavinginterpersonalproblemsand
studentswhohaveproblemswiththeirstudies.Thereisregulartrainingcoursein
counseling in CMC, Vellore. Training Village Leaders: Training
village leaders to work like referral and change agents in the
society has yielded mixed results. Student Volunteers: As part of
NSS, College students were educated about mental
illnessandweremotivatedtoextendsocialservicestomentallyill.Thistraining
decreased authoritative and negative attitudes in the trained
students, compared to the control group. The trained students were
allotted to interact with mentally ill in a
hospitalsetup,withacontrolgroupofpatientswhowerenotexposedtosuch
interaction.Sixmonthslater,itwasfoundthattheconditionofexperimentalgroup
hadimprovedsignificantly.Thus,thecollegestudentscanformoneofthe
community resources to manage the mentally ill. Student enrichment
program: poor classroom performance and poor performance in
examinations are the common problems in almost all the schools.
These children
aresubjectedtohumiliationandpunishmentbyparentsandteachers.Astudent
enrichment program of 30 sessions has been developed. Subjects like
how to study,
howtolearnbetter,howtocommunicateandwriteintheexamination,androleof
emotional factors in learning are dealt with.
NonGovernmentalvoluntaryorganizations:Manynon-governmental
organizationsareworkingintheareaofmentalhealth.Therearemanysuicide
preventioncentresinIndiainthevoluntarysectordoinggoodwork,helpingthose
who need help. Helping Hand and MPA (Medico-Pastoral Association)
in Bangalore, Sneha in Chennai, Sahara in Mumbai, Sanjivini and
Sumaithri in New Delhi are the few examples. SUMMARY:
Inthisseminarwehadlearnedaboutthedefinitionofcommunitymental
health, historical development of community mental health,
development of community mental health service in India,
Inspiration for the community mental health movement in
Indiacomesfromthreesources,criticalaccountofthemental
healthservices inIndia and alternatives to institutional care.
CONCLUSION:
Operationallycommunitymentalhealthmeanstheprocessofinvolvingin
raisingthelevelofmentalhealthamongpeopleinacommunityandreducingthe
numberofthosesufferingfrommentaldisorders.Hencecommunitycarehasabetter
effectthaninstitutionaltreatmentontheoutcomeandqualityoflifeofindividualswith
chronic mental disorders. Community based services can lead to
early intervention and reduce the stigma of taking treatment.
BIBLIOGRAPHY: GAIL W.STUART Principles and practice of Psychiatric
Nursing eighth edition; published by Mosby; page no: 779
Dr.K.LALITHA; Mental Health and Psychiatric Nursing an Indian
Perspective; First Edition 2007; VMG Book house publishers; page
No: 635-641 KAREN SAUCIER LUNDY AND SHARYN JANES; Essentials of
Community based Nursing; First edition 2003; Jones and Barlett
publishers; page no: 34 STANHOPE LANCASTER; Community health
Nursing Process and Practice for promoting health Third Edition;
1992; Mosby Publishers; page no:45-50
K.PARK.,TextBookOfPreventiveAndSocialMedicine20thEdition,M/s.
Banarsidas Banot Publisher., Jabalpur., NET REFERENCE:
yhttp://www.pubmed.nl/
yhttp://nnlm.gov/training/resources/pmtri.pdf
ywww.ncbi.nlm.nih.gov/pubmed yhttp://www.theluncet.com/|ournul
Developing Community Mental Health Services Report of the Regional
Workshop Bangkok, Thailand, 11-14 December 2006 (1) Currently,
mental health services are extremely limited in some Member States,
particularly in rural and remote areas. (2) The treatment gap for
mental illnesses is huge, leading to substantial preventable
morbidity in the community. Given the availability of knowledge and
appropriate medications, this needs urgent attention. Even though
there is a scarcity of mental health services in Member States,
even existing mental health services are not being optimally
utilized. (3) A substantial proportion of mental health care is
provided by the private sector, mostly by the informal sector
(faith healers, religious healers, traditional healers). This issue
needs to be addressed by governments, professionals and civil
society. A sensitive issue is: can this sector be constructively
engaged as limited partners (4) The existing mental health services
in most Member States need to be improved. The quality of service
is poor and there are numerous human rights violations. (5)
Community mental health care is the optimum direction for future
development of mental health services by Member States. This is
based on the following observations: (a)Evidence that
community-based mental health care is superior to psychiatry
hospital-based care. (b) Great scarcity of qualified mental health
professionals to meet all the needs of the community. (c)Problems
in transportation of patients from their homes to tertiary-care
hospitals. (d) Preference of people to seek health care
(e)Preference of people to seek health care locally in the
community. (6) Community mental health service should be integrated
into the existing primary health care delivery system to ensure its
long term sustainability. (7) The capacity of staff at the primary
health care level should be enhanced through appropriate training.
Care should be taken not to over-burden the PHC staff with too many
details which are not essential at the primary care level.
Different countries may use different models, e.g. dedicated mental
health worker (Sri Lanka) or enhancing the capacity of general PHC
staff (Indonesia). (8) Countries should consider whether the
successful Thai model of Village Health Volunteers can be
replicated, or paid workers are needed. (9)Mental health care is
closely linked to the culture of the community, thus
culturally-sensitive programmes should be developed, e.g. the
deeply religious beliefs, strong family ties of the regional
countries, etc. (10) Community mental health services should meet
all the mental health needs of the community, including mental
health promotion, prevention of mental illness, psychosocial needs
of the community, needs of special groups (adolescents, elderly,
refugees, etc.), prevention of harm from substance abuse, etc. (11)
Community awareness programmes are urgently needed focusing on
issues such as: (a) Medical nature of mental illness (b) Changing
the health-seeking behavior of the community (c) Stigma removal (d)
Removal of myths and misconceptions (e) Ensure community ownership
of the programme (f) Communities and families need to be prepared
to care for Persons with mental illness. (12) Traditional methods
and practices (traditional healers, faith Healers, religious
healers) should be scientifically evaluated. If appropriate and
effective, they should be promoted. New programmes being developed
should be evidence-based and periodically evaluated for their
impact
MASTER PLAN S.NO CONTENT PAGE NO 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
INTRODUCTION DEFINITION OF COMMUNITY MENTAL HEALTH HISTORICAL
DEVELOPMENT OF COMMUNITY MENTAL HEALTH INSPIRATION FOR THE
COMMUNITY MENTAL HEALTH MOVEMENT IN INDIA CRITICAL ACCOUNT OF THE
MENTAL HEALTH SERVICES IN INDIA ALTERNATIVES TO INSTITUTIONAL CARE.
SUMMARY CONCLUSION BIBLIOGRAPHY JOURNAL REFERENCE
