COMMUNITY PSYCHIATRY
During the second half of the 20th century and specially in its last decade, mentally ill people have been moved out of the relative simplicity of the large Institution with its clear structure and hierarchies and into the community which may be regarded as a third Psychiatric revolution. Prior to that Phillippe Pinel in France, William Tuke in Greet Britain, Dorothea Dix in Columbia (USA) tried to provide moral treatment for the mentally sick person by treating them in the Asylums.
In 1909 Adollph Meyer with William Jones and Beers started the Mental Hygiene movement in USA.
During the second half of the 20th century and specially in its last decade, mentally ill people have been moved out of the relative simplicity of the large Institution with its clear structure and hierarchies and into the community which may be regarded as a third Psychiatric revolution. Prior to that Phillippe Pinel in France, William Tuke in Greet Britain, Dorothea Dix in Columbia (USA) tried to provide moral treatment for the mentally sick person by treating them in the Asylums.
In 1909 Adollph Meyer with William Jones and Beers started the Mental Hygiene movement in USA.
During World War II, Thomas Salmon first started the short term model for crisis intervention for soldiers emphasizing immediate treatment close to the stressful situation. Thereafter Social Science Researchers like Maxwell Jones advocated the concept of Therapeutic Community. The Menninger Hospital first established the first day hospital.
The advent of the first anti psychiatric drug Chlorpromazine has led to the deinstitutalization of many of the mentally sick persons to start Community Psychiatry programme.
The advent of the first anti psychiatric drug Chlorpromazine has led to the deinstitutalization of many of the mentally sick persons to start Community Psychiatry programme.
Definition of Community Psychiatry (Oxford Textbook of Community Psychiatry Thornicroft and Szmukler)
Community Psychiatry comprises the principles and practices needed to provide mental health services for a local population by –
(i) Establishing population based needs for treatment and care.
(ii) Providing a service system linking a wide range of resources of adequate capacity, operating in accessible locations and ,
(iii) Delivering evidence based treatment to people with mental disorders.
The American Heritage and Stedman’s Medical Dictionary 2nd edition defines Community Psychiatry as the discipline focusing on detection, prevention, early treatment and rehabilitation of emotional and behavioural disorders as they develop in a community.
Thornicroft and Tansella (1999) defined a Community based mental health service is one which provides a full range of effective mental health care to a defined population and which is dedicated to treating and helping people with mental disorders, in proportion to their suffering or distress, in collaboration with other local agencies.
Background information:
Mental disorders have been viewed as a curse, as a result of bad deeds in the lifetime or in the past, or as an infliction caused by others for revenge. In India, even in the Vedic age of Charaka and Sushruta, efforts were made to under stand and classify mental disorders. There had been mention of these as ‘Unmads’ in the Charaka Samhita. In Ayurveda there was mention of management of the mentally ill by religious rituals, prayers and herbal medicines like Rowlfia Serpentina ,Cannabis, and Alcohol along with restriction of certain foods.
Organized mental health care in the form of Mental Asylum was started in India by the British in the year 1745 in Bombay. As such it was not for proper treatment of the mentally ill persons, rather they were kept in the asylum isolated, so that they could not disturb the normal people in the society. The set up was inhumane as the patients were kept in the asylum like the convicts in a jail. There were however public movements in France, Britain and the United States of America against such ill treatment and moral treatment was subsequently started which included human care, avoiding physical restraints, better staff patient interaction and an open door system.
In 1909, Adolf Meyer advocated management of mentally ill patients outside the institutions and proposed a comprehensive ‘community mental health approach’ in which psychiatrists, family physicians, police, teachers and social workers would work together to organize primary, secondary and tertiary preventive measures in the community.
Community Psychiatry comprises the principles and practices needed to provide mental health services for a local population by –
(i) Establishing population based needs for treatment and care.
(ii) Providing a service system linking a wide range of resources of adequate capacity, operating in accessible locations and ,
(iii) Delivering evidence based treatment to people with mental disorders.
The American Heritage and Stedman’s Medical Dictionary 2nd edition defines Community Psychiatry as the discipline focusing on detection, prevention, early treatment and rehabilitation of emotional and behavioural disorders as they develop in a community.
Thornicroft and Tansella (1999) defined a Community based mental health service is one which provides a full range of effective mental health care to a defined population and which is dedicated to treating and helping people with mental disorders, in proportion to their suffering or distress, in collaboration with other local agencies.
Background information:
Mental disorders have been viewed as a curse, as a result of bad deeds in the lifetime or in the past, or as an infliction caused by others for revenge. In India, even in the Vedic age of Charaka and Sushruta, efforts were made to under stand and classify mental disorders. There had been mention of these as ‘Unmads’ in the Charaka Samhita. In Ayurveda there was mention of management of the mentally ill by religious rituals, prayers and herbal medicines like Rowlfia Serpentina ,Cannabis, and Alcohol along with restriction of certain foods.
Organized mental health care in the form of Mental Asylum was started in India by the British in the year 1745 in Bombay. As such it was not for proper treatment of the mentally ill persons, rather they were kept in the asylum isolated, so that they could not disturb the normal people in the society. The set up was inhumane as the patients were kept in the asylum like the convicts in a jail. There were however public movements in France, Britain and the United States of America against such ill treatment and moral treatment was subsequently started which included human care, avoiding physical restraints, better staff patient interaction and an open door system.
In 1909, Adolf Meyer advocated management of mentally ill patients outside the institutions and proposed a comprehensive ‘community mental health approach’ in which psychiatrists, family physicians, police, teachers and social workers would work together to organize primary, secondary and tertiary preventive measures in the community.
The community programme in the real sense is a peoples programmes.
In 1952, the committee on mental health of the World Health Organization recommended components for a community mental hospital which included outpatient treatment, part time service, rehabilitation, research and community education.
In the USA the community mental health movement had its rise and fall between 1950s and 1980s. There were a very large numbers of mental patients in the state hospitals. In New York City itself there were 91,000 beds for mental patients. In 1963, President J. F. Kennedy passed a resolution and the US congress passed the community mental health centre act to establish community mental health centers to offer care to the patients discharged from the mental hospitals. These centers provided outpatient as well as inpatient care, emergency services, crises management, community consultation and education. These centers had multidisciplinary team consisting of psychiatrists, clinical psychologists, psychiatric social workers, occupational therapists involved in the service, and linkage were established with schools, welfare workers and agencies and families of the mentally ill in the community. By this approach there was effective management and the total number of mental hospital beds of 5,60,000 in 1955 was brought down to 61,000 in 1992.
In spite of all such community approach movement in other parts of the globe, in India, the situations remained same and new mental hospitals were established till 1966; and number of hospitals from 17 in 1946 rose to 48 in 1992. But barring a few exceptions, the conditions of most of these hospitals remained unsatisfactory because of paucity of fund, lack of mental health professionals, lack of training of the existing staff and poor administration. The general hospitals in 1960s and 1970s opened up psychiatric department in many places with inpatient facilities. The Mudaliar committee in 1962 envisaged that within the next 10 years psychiatric units would be set up in all the district hospitals of the country. Even now, majority of the districts except in Kerala, Karnataka and Tamil Nadu, do not have such units. In Assam, out of 23 districts there are only 5 district hospitals with psychiatric units. Such unit in the district hospitals would have the advantage over the mental hospitals because they would be easily accessible, approachable without stigma, would facilitate outpatient treatment for minor mental health problems and would help in integration of psychiatric services into the general health system.
The inspiration for the community mental health movement in India comes from the sources like:
1. The adoption of community mental health programme by USA in 1963 when the American Psychiatrists realized about Social Breakdown Syndrome resulting from long term hospitalization.
2. The realization of the fact that Institution based psychiatry through trained professionals is very expensive and countries like India do not have sufficient manpower and facilities to deliver Mental Health services through conventional method.
3. The discovery in poor countries like India that para professional ]s and non professionals too can deliver reasonably adequate mental health care after undergoing simple and short innovative training.
Psychiatric Unit in General Hospitals –
As a part of deinstitutionalization, many part of the country established General Hospital Psychiatric units, the first one was set up in 1933 at the R.G. Kar Medical College at Kolkata. Most of such units came up after 1960's after advent of antipsychotic drugs. In the west, the GHPU were created to attend to Neuroses and psychiatric illness, but those in India handled all kinds of psychiatric problems. This gave a new sense of confidence to both the Psychiatrists and patients.
In India, however the pathetic scenario continued for a long time. Queen Victoria of England, in 1920 passed an order to convert all the mental asylums as mental hospitals and the order was carried out in India also. The conditions of the asylum and the administrative functions remained same with the same design for detention and safe custody without regard for curative treatment. The existing accommodation was also not adequate for the number of patients kept. At the time of independence, there was only one mental hospital bed for 40,000 population in India, whereas in England it was one for 300 population.
As per recommendation of the Bhore Committee set up in 1946, the National Institute of Mental Health and Neurosciences (NIMHANS) was established in Bangalore in 1954 for training of mental health professionals. In 1957, Dr. Vidya Sagar, the then Superintendent of Amritsar Mental Hospital started involvement of family members in treatment of the patients by keeping the patient with family members in open tents pitched in the hospital campus. The result was very much satisfactory as the patients recovered rapidly and could go back home with the family members. The family members also could understand the procedures to tackle the problems of the patients and relapse rate was low. Based on the success of this approach NIMHANS of Bangalore and Christian Medical College of Vellore established family wards in their hospitals. This happened before the era of major tranquilizers.
In the 1970s another approach was considered for mental health care. The existing centers offering mental health care served only 20% of the population and that too in urban areas only, whereas 70% of the total population used to live in rural areas. All the epidemiological studies conducted in India revealed that mental morbidity was almost same in rural and urban areas. People could not or did not make use of the available services because of the following reasons:-
1. Ignorance about the available services
2. Existing belief that mental disorders are caused by evils spirits or black magic or due to bad deeds.
3. Lack of knowledge regarding modern method of treatment available
4. Long distance to the centers offering services
5. Social stigma
6. Lack of financial resources to meet the cost of transport, accompanying persons and other costs.
A primary care approach was therefore necessary to cover the rural population through the primary care centers available in rural areas. In 1975, the World Health Organization (WHO) established a report on organization of mental health care in developing countries. In the report, WHO strongly recommended the delivery of mental health services through primary care system as a policy for the developing countries. Efforts were made to implement the primary care approach in the country. One center was established by the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, in 1975 at Raipur Rani Block of Ambala district of Haryana and another by NIMHANS, Bangalore, in 1976 at Sakalwara village in Karnataka. The Central Institute of Psychiatry Ranchi first started Rural Mental Health Center in 1964. A workshop at Madras in 1971 organized by Indian Psychiatric Society recommended that adequate training in mental health should be imparted to increase the workforce including General practitioner, Medical Officers, Nurses, health visitors, midwives, social workers ,gramsewaks and voluntary organization.
The NIMHANS Crash Programme
At the initiative of the Director Dr. R. M. Varma and Dr. Karan Singh, Minister of Health in the Central Govt. a crash programme for community based mental health was introduced at NIMHANS along with the starting of Community Psychiatry Unit in October 1975.
The following experimental programme was launched by this unit -
1. Primary Health Center based rural mental health programme - training of multipurpose workers and PHC doctors were organized.
2. General Practitioner (GP) based urban, mental health programme - a manual was prepared to train GPS in treating common mental health disorders.
3. School Mental Health programme - where teachers were trained to diagnose children with emotional problems with counseling.
4. Home based follow up of psychiatric patients where nurses were trained to follow up patients by home visits.
5. Psychiatric camps were organized like other health check up camps.
A feasibility study was conducted from 1975 to 1980 in both the centers of NIMHANS and PGIMER i.e. Sakalwara and Raipur respectively. The study revealed that;
1. Majority of the mentally ill Epileptics and mentally retarded children remained untreated in spite of being nearer to a well established Psychiatric hospital.
2. All the families of the affected had approached traditional healing centers and local healers but in vain.
3. Majority of the patients with psychoses and epilepsy were ill for more than two years.
4. Key informants, health workers and others could easily identify and report.
5. A limited numbers of drugs like Chlorpromazine, Trifluperazine, Diazepam, Fluphenazine decanoate, Imipramine, Phenobarbitone, Trihexyphenidyl were sufficient to manage almost all cases.
6. Most of the Psychotics improved with medication and were rehabilitated within their villages. Improved patients were accepted to join the mainstream of life without stigma.
7. Medical and non-medical workers were able to learn to manage priority mental disorders in short term courses.
Considering the various factors NIMHANS and other institutions developed other alternatives to institutional care, such as :-
Extensive use of outpatient services.
Extension programme by satellite clinics.
Domiciliary care programme through trained paramedical staff.
Organizing care through private general practitioners.
Training of school teachers in mental healthcare and promotion of mental health care through schools.
Involvement of ICDS personnel in child mental health care.
Training of non-medical volunteers.
Training of college student volunteers.
Training of village leaders
Student enrichment programme.
Involvement of non governmental voluntary organizations.
National Mental Health Programme ( 1982 ) :
In 1982, the health administration in India recognized the need for mental health care and the National Mental Health Programme 1982 (NMHP) was launched all over the country. The main objectives of the programme are –
1. Prevention and treatment of mental and neurological disorder and their associated disabilities and to promote community participation in the organization of services.
2. Use of mental health technology to improve general health services.
3. Applications of Mental Health Principles in total National development to improve quality of life.
In the USA the community mental health movement had its rise and fall between 1950s and 1980s. There were a very large numbers of mental patients in the state hospitals. In New York City itself there were 91,000 beds for mental patients. In 1963, President J. F. Kennedy passed a resolution and the US congress passed the community mental health centre act to establish community mental health centers to offer care to the patients discharged from the mental hospitals. These centers provided outpatient as well as inpatient care, emergency services, crises management, community consultation and education. These centers had multidisciplinary team consisting of psychiatrists, clinical psychologists, psychiatric social workers, occupational therapists involved in the service, and linkage were established with schools, welfare workers and agencies and families of the mentally ill in the community. By this approach there was effective management and the total number of mental hospital beds of 5,60,000 in 1955 was brought down to 61,000 in 1992.
In spite of all such community approach movement in other parts of the globe, in India, the situations remained same and new mental hospitals were established till 1966; and number of hospitals from 17 in 1946 rose to 48 in 1992. But barring a few exceptions, the conditions of most of these hospitals remained unsatisfactory because of paucity of fund, lack of mental health professionals, lack of training of the existing staff and poor administration. The general hospitals in 1960s and 1970s opened up psychiatric department in many places with inpatient facilities. The Mudaliar committee in 1962 envisaged that within the next 10 years psychiatric units would be set up in all the district hospitals of the country. Even now, majority of the districts except in Kerala, Karnataka and Tamil Nadu, do not have such units. In Assam, out of 23 districts there are only 5 district hospitals with psychiatric units. Such unit in the district hospitals would have the advantage over the mental hospitals because they would be easily accessible, approachable without stigma, would facilitate outpatient treatment for minor mental health problems and would help in integration of psychiatric services into the general health system.
The inspiration for the community mental health movement in India comes from the sources like:
1. The adoption of community mental health programme by USA in 1963 when the American Psychiatrists realized about Social Breakdown Syndrome resulting from long term hospitalization.
2. The realization of the fact that Institution based psychiatry through trained professionals is very expensive and countries like India do not have sufficient manpower and facilities to deliver Mental Health services through conventional method.
3. The discovery in poor countries like India that para professional ]s and non professionals too can deliver reasonably adequate mental health care after undergoing simple and short innovative training.
Psychiatric Unit in General Hospitals –
As a part of deinstitutionalization, many part of the country established General Hospital Psychiatric units, the first one was set up in 1933 at the R.G. Kar Medical College at Kolkata. Most of such units came up after 1960's after advent of antipsychotic drugs. In the west, the GHPU were created to attend to Neuroses and psychiatric illness, but those in India handled all kinds of psychiatric problems. This gave a new sense of confidence to both the Psychiatrists and patients.
In India, however the pathetic scenario continued for a long time. Queen Victoria of England, in 1920 passed an order to convert all the mental asylums as mental hospitals and the order was carried out in India also. The conditions of the asylum and the administrative functions remained same with the same design for detention and safe custody without regard for curative treatment. The existing accommodation was also not adequate for the number of patients kept. At the time of independence, there was only one mental hospital bed for 40,000 population in India, whereas in England it was one for 300 population.
As per recommendation of the Bhore Committee set up in 1946, the National Institute of Mental Health and Neurosciences (NIMHANS) was established in Bangalore in 1954 for training of mental health professionals. In 1957, Dr. Vidya Sagar, the then Superintendent of Amritsar Mental Hospital started involvement of family members in treatment of the patients by keeping the patient with family members in open tents pitched in the hospital campus. The result was very much satisfactory as the patients recovered rapidly and could go back home with the family members. The family members also could understand the procedures to tackle the problems of the patients and relapse rate was low. Based on the success of this approach NIMHANS of Bangalore and Christian Medical College of Vellore established family wards in their hospitals. This happened before the era of major tranquilizers.
In the 1970s another approach was considered for mental health care. The existing centers offering mental health care served only 20% of the population and that too in urban areas only, whereas 70% of the total population used to live in rural areas. All the epidemiological studies conducted in India revealed that mental morbidity was almost same in rural and urban areas. People could not or did not make use of the available services because of the following reasons:-
1. Ignorance about the available services
2. Existing belief that mental disorders are caused by evils spirits or black magic or due to bad deeds.
3. Lack of knowledge regarding modern method of treatment available
4. Long distance to the centers offering services
5. Social stigma
6. Lack of financial resources to meet the cost of transport, accompanying persons and other costs.
A primary care approach was therefore necessary to cover the rural population through the primary care centers available in rural areas. In 1975, the World Health Organization (WHO) established a report on organization of mental health care in developing countries. In the report, WHO strongly recommended the delivery of mental health services through primary care system as a policy for the developing countries. Efforts were made to implement the primary care approach in the country. One center was established by the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, in 1975 at Raipur Rani Block of Ambala district of Haryana and another by NIMHANS, Bangalore, in 1976 at Sakalwara village in Karnataka. The Central Institute of Psychiatry Ranchi first started Rural Mental Health Center in 1964. A workshop at Madras in 1971 organized by Indian Psychiatric Society recommended that adequate training in mental health should be imparted to increase the workforce including General practitioner, Medical Officers, Nurses, health visitors, midwives, social workers ,gramsewaks and voluntary organization.
The NIMHANS Crash Programme
At the initiative of the Director Dr. R. M. Varma and Dr. Karan Singh, Minister of Health in the Central Govt. a crash programme for community based mental health was introduced at NIMHANS along with the starting of Community Psychiatry Unit in October 1975.
The following experimental programme was launched by this unit -
1. Primary Health Center based rural mental health programme - training of multipurpose workers and PHC doctors were organized.
2. General Practitioner (GP) based urban, mental health programme - a manual was prepared to train GPS in treating common mental health disorders.
3. School Mental Health programme - where teachers were trained to diagnose children with emotional problems with counseling.
4. Home based follow up of psychiatric patients where nurses were trained to follow up patients by home visits.
5. Psychiatric camps were organized like other health check up camps.
A feasibility study was conducted from 1975 to 1980 in both the centers of NIMHANS and PGIMER i.e. Sakalwara and Raipur respectively. The study revealed that;
1. Majority of the mentally ill Epileptics and mentally retarded children remained untreated in spite of being nearer to a well established Psychiatric hospital.
2. All the families of the affected had approached traditional healing centers and local healers but in vain.
3. Majority of the patients with psychoses and epilepsy were ill for more than two years.
4. Key informants, health workers and others could easily identify and report.
5. A limited numbers of drugs like Chlorpromazine, Trifluperazine, Diazepam, Fluphenazine decanoate, Imipramine, Phenobarbitone, Trihexyphenidyl were sufficient to manage almost all cases.
6. Most of the Psychotics improved with medication and were rehabilitated within their villages. Improved patients were accepted to join the mainstream of life without stigma.
7. Medical and non-medical workers were able to learn to manage priority mental disorders in short term courses.
Considering the various factors NIMHANS and other institutions developed other alternatives to institutional care, such as :-
Extensive use of outpatient services.
Extension programme by satellite clinics.
Domiciliary care programme through trained paramedical staff.
Organizing care through private general practitioners.
Training of school teachers in mental healthcare and promotion of mental health care through schools.
Involvement of ICDS personnel in child mental health care.
Training of non-medical volunteers.
Training of college student volunteers.
Training of village leaders
Student enrichment programme.
Involvement of non governmental voluntary organizations.
National Mental Health Programme ( 1982 ) :
In 1982, the health administration in India recognized the need for mental health care and the National Mental Health Programme 1982 (NMHP) was launched all over the country. The main objectives of the programme are –
1. Prevention and treatment of mental and neurological disorder and their associated disabilities and to promote community participation in the organization of services.
2. Use of mental health technology to improve general health services.
3. Applications of Mental Health Principles in total National development to improve quality of life.
The approaches to achieve these objectives are –
1. Diffusion of mental health skills to the periphery of the health service systems.
2. Appropriate allotment of task in mental health care for different levels of health personals.
3. Equitable and balanced territorial distribution of resources.
4. Integration of basic mental health care into general health services.
5. Linkage to community development.
1. Diffusion of mental health skills to the periphery of the health service systems.
2. Appropriate allotment of task in mental health care for different levels of health personals.
3. Equitable and balanced territorial distribution of resources.
4. Integration of basic mental health care into general health services.
5. Linkage to community development.
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