CHANGING FOCUS OF CARE IN COMMUNITY MENTAL

HEALTH
INTRODUCTION:
Community Mental health ia an idea, a philosophy, an enactment
that came to reality in 1963 with the late American President John F. Kennedys Bold
New Approach. The community mental health movement represents the fourth
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
state assume responsibility for its mentally ill. The result was the establishment of 32
mental hospitals in the United States. Most mental hospitals were built in rural areas,
which offered inexpensive land, the removal of troublesome people from the
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
Community mental health describes a change in focus of psychiatric
mental health care from the individual to the individual in interaction with his
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 them and it should be available to
all, regardless of personal characteristics such as age, ability to pay, or place of
residence. They could be treated in freestanding community mental health centres, in
treatment units of general hospitals and in translational homes.
-Dr.K.Lalitha
HISTORICAL DEVELOPMENT OF COMMUNITY MENTAL HEALTH
The community mental health care services started with an aim of providing
mental health treatment in the community and thus to greatly reduce the census
of large public psychiatric hospitals located at a distance from the homes and
families of patients.
Initially it was designed to provide five basic services: outpatient, partial
hospitalization, inpatient, emergency and consultation and education
Subsequently it extended its service to children and geriatrics
The community mental health program created a community based system of
mental health care
A wide range of mental health services became available in communities.
Innovative services like mental health consultation to schools, geriatric homes,
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
In 1975, the World Health Organization strongly recommended the delivery of
mental health services through Primary Health system as a policy for the
developing countries.
In India, before Independence, there were no clear plans for the care of the
mentally ill patients. The approach was largely to build asylums which were
custodial rather than therapeutic
In 1946, Bhore committee recommended to increase manpower in the field of
mental health.
In 1962, the Mudaliar committee envisaged psychiatric services at all district
hospitals.
Later in 1975, an attempt was made by PGI, Chandigarh to develop a model of
psychiatric services in the PHC, Raipur Rani Block of Ambala District, 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
hospitals to psychiatric units of general hospitals and to community care. 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)
The realization of the magnitude of severe mental disorders in the rural
community (at least 1%) is as same as in the urban community and availability of
simple interventions for these conditions
The successful experience of community mental health care of Bangalore and
Chandigarh.

DEVELOPMENT OF COMMUNITY MENTAL HEALTH SERVICES IN INDIA
y The institutional treatment for mental disorders in India and the use of allopathic
medicine were introduced by the European rulers.
y Charaka and others practiced indigenous medical systems considered mental
disorders to be asadhya (unmanageable)
y Thus their treatment was left to folk healers, who practiced their art in the
community setting.
y In 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
y There were 26 traditional healers for a population of 10,000 which is a fair
therapist patient ratio by any standard,




INSPIRATION FOR THE COMMUNITY MENTAL HEALTH MOVEMENT IN INDIA
COMES FROM THREE SOURCES
o The 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.
o Institution based psychiatry care through trained professionals can be very
expensive and country like India cannot afford to prepare sufficient manpower
o The contribution of para- professionals and non professionals with simple and
short training delivered reasonably adequate mental health care.
CRITICAL ACCOUNT OF THE MENTAL HEALTH SERVICES IN INDIA
1. In the late 1950s Dr. Vidyasagar began to involve family members in the
treatment of mentally ill patients who were admitted to the Amritsar mental
Hospital. This approach
- Reduced the hostility in the minds of the patients for having been abandoned
in a strange place
- Helped to remove the age-old myths about the incurability of mental illness
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
many patients actually went back with their families and the discharge
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
- The Director Dr. R.M.Varma and Dr. Karan Singh, Minister of health in the
Central Government, jointly introduced community based mental health
program at NIMHANS
- In October, 1975, a community Psychiatry Unit (CPU) was started. It initiated
the following activities
# Primary health centre based rural mental health programme: A manual was
prepared to train the multipurpose health workers to recognize cases of severe mental
illness and follow them under the leadership of the PHC doctor. Another manual was
prepared to train the doctors to diagnose cases of severe mental disorders and treat
them
# General practitioner based urban mental health programme: a manual was
prepared to teach GP methods of treating common mental disorders
# School mental health program: school teachers were trained to diagnose
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.
Rural mental health program was started at a health centre in the
village of sakalwara, near Bangalore. It conducted 15 days training program to PHC
personnel on regular basis and they carried out the follow up services in the absence of
supervision by professionals.
4. The Chandigarh Experiment
- A rural mental health programme was started in the PGIMER, Chandigarh
with the help of WHO. Manuals were developed and training for the PHC
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. The National Mental Health programme (1982) was launched to ensure the
availability and accessibility of minimum mental health care for all in the
foreseeable future
7. The District Mental Health Programme was launched as a pilot model
programme in the Bellary District by NIMHANS in 1980s
8. The national workshops on mental health care for the state health administrators
held at NIMHANS in 1996 and the workshop to review the DMHP in October
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. Involvement of lay volunteers to counsel the mentally sick. A short period of
training is given to them
11. Many industrial organizations provided personality-enhancement programs for
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, Bangalore and other institutions have developed other
alternatives to institutional care
Extensive use of outdoor services: Family members are encouraged to treat their
patients at home and get drugs and suggestions from the hospital by periodic
regular visits. All types of treatment, including ECT, are given in the outpatient
setups. Short stay wards (for few hours to 48 hours) facility is organized in out
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
monthly clinic at taluk or district headquarters. The local medical and non-
governmental voluntary organizations are motivated to be the local hosts and help in
patient care. Such satellite clinics are functioning successfully in 6 centres of
Karnataka and few centres in other parts of the country.

Domiciliary care program: a mental health professional or a visiting nurse delivers
the required services to the patients at their door steps. In a study, the urban
schizophrenic patients were treated at home and followed up for 6 months.
Compared to the hospitalized patients, the home group consistently did better both
in clinical state and social functioning.

Organizing care through private general Practitioners: short term courses are
arranged to improve the knowledge and skills of private general practitioners in
managing psychiatric problems seen in their routine practice. They are easily
accepted by people and delivered good care for the needy. They have to be
supported by mental health professionals, by being available for consultation in
managing difficult cases.

Training school teachers in mental health care and promotion of mental health
through schools: Training programs are organized in two phases for school
teachers in recognizing and managing psychosocial problems of students through
counseling. The experience so far indicates that it is possible to sensitize teachers in
recognizing and intervening when faced with problems pertaining to mental health.
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.

Training lay volunteers: Interested and committed natural helpers in the
community are given 40 sessions of training in counseling, so that they can help
individuals who are in distress because of psychosocial problems. They have to be
supervised and monitored by mental health professionals. In voluntary sector, there
are several counseling centres offering services to people with marital discord,
people with problem children, people who are having interpersonal problems and
students who have problems with their studies. There is regular training course in
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
illness and were motivated to extend social services to mentally ill. This training
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
hospital set up, with a control group of patients who were not exposed to such
interaction. Six months later, it was found that the condition of experimental group
had improved significantly. Thus, the college students can form one of the
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
are subjected to humiliation and punishment by parents and teachers. A student
enrichment program of 30 sessions has been developed. Subjects like how to study,
how to learn better, how to communicate and write in the examination, and role of
emotional factors in learning are dealt with.

Non Governmental voluntary organizations: Many non-governmental
organizations are working in the area of mental health. There are many suicide
prevention centres in India in the voluntary sector doing good work, helping those
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:
In this seminar we had learned about the definition of community mental
health, historical development of community mental health, development of community
mental health service in India, Inspiration for the community mental health movement in
India comes from three sources, critical account of the mental health services in India
and alternatives to institutional care.
CONCLUSION:
Operationally community mental health means the process of involving in
raising the level of mental health among people in a community and reducing the
number of those suffering from mental disorders. Hence community care has a better
effect than institutional treatment on the outcome and quality of life of individuals with
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., Text Book Of Preventive And Social Medicine 20
th
Edition, M/s.
Banarsidas Banot Publisher., Jabalpur.,


NET REFERENCE:

y http://www.pubmed.nl/
y http://nnlm.gov/training/resources/pmtri.pdf
y www.ncbi.nlm.nih.gov/pubmed
y http://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

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CONTENT

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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