Psychiatry as applied to the community

1. COMMUNITY
PSYCHIATRY
P R E S E N T E R – D R . S R I R A M . R , F I N A L Y E A R P G I N P S Y C H I A T R Y
C H A I R P E R S O N – D R . S A I , A S S I S T A N T P R O F O F P S Y C H I A T R Y

2. ORGANISATION OF THE TOPIC
• WHAT IS A COMMUNITY?
• DEFINITIONS OF COMMUNITY PSYCHIATRY
• COMMUNITY MENTAL HEALTH SERVICES
• COMMUNITY PSYCHIATRY OUTSIDE INDIA
– DEVELOPMENT IN THE UNITED STATES
– THE ITALIAN MOVEMENT
• DEVELOPMENT OF COMMUNITY PSYCHIATRY IN INDIA
– INTRODUCTION
– HISTORY
– OBJECTIVES OF NMHP
– PROGESS SINCE 1982
– THE RANCHI EXPERIMENT
– OTHER ORGANISATIONS
– CONTRIBUTION OF INDIAN MENTAL HEALTH ACT 1987
• PROS AND CONS OF COMMUNITY PSYCHIATRY MOVEMENT IN INDIA
• INITIATIVES BY INSTITUTE OF MENTAL HEALTH
• REFERENCES

3. WHAT IS A COMMUNITY?
• Full Definition of COMMUNITY (MERRIAM-WEBSTER DICTIONARY)
• plural com·mu·ni·ties
• 1 : a unified body of individuals: as a : STATE, COMMONWEALTH b : the people
with common interests living in a particular area; broadly : the area itself<the problems of
a large community>c : an interacting population of various kinds of individuals (as species)
in a common location d : a group of people with a common characteristic or interest living
together within a larger society <a community of retired persons>e : a group linked by a
common policy f : a body of persons or nations having a common history or common
social, economic, and political interests <the international community>g : a body of
persons of common and especially professional interests scattered through a larger
society <the academic community>
• 2 : society at large
• 3a : joint ownership or participation <community of goods>b : common
character : LIKENESS <community of interests>c : social activity : FELLOWSHIP d : a social
state or condition

4. DEFINITIONS OF COMMUNITY PSYCHIATRY
• Psychiatry focusing on the detection, prevention, early treatment,
and rehabilitation of patients with emotional disorders and social
deviance as they develop in the community rather than as
encountered one-on-one, in private practice, or at larger centralized
psychiatric facilities; particular emphasis is placed on the social-
interpersonal-environmental factors that contribute to mental illness.
~ Farlex Partner Medical Dictionary © Farlex 2012
• Psychiatry focusing on detection, prevention, early treatment, and
rehabilitation of emotional and behavioral disorders as they develop
in a community.
~ The American Heritage® Medical Dictionary

5. DEFINITIONS OF 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.
~ Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.
• Psychiatry focusing on the detection, prevention, early treatment,
and rehabilitation of patients with emotional disorders and social
deviance as they develop in the community.
~ Medical Dictionary for the Health Professions and Nursing © Farlex 2012

6. COMMUNITY MENTAL HEALTH SERVICES
• Community mental health services (CMHS), also known as Community
Mental Health Teams (CMHT) in the United Kingdom, support or treat
people with mental disorders (mental illness or mental health
difficulties) in a domiciliary setting, instead of a psychiatric hospital
(asylum).
• It refers to a system of care in which the patient's community, not a
specific facility such as a hospital, is the primary provider of care for
people with a mental illness.

7. COMMUNITY MENTAL HEALTH SERVICES
• Services include supported housing with full or partial supervision
(including halfway houses), psychiatric wards of
general hospitals (including partial hospitalization), local primary
care medical services, day centers or clubhouses, community mental
health centers, and self-help groups for mental health.
• The services may be provided by government organizations
and mental health professionals, including specialized teams
providing services across a geographical area, such as assertive
community treatment and early psychosis teams.

8. COMMUNITY MENTAL HEALTH SERVICES
• They may also be provided by private or charitable organizations.
They may be based on peer support and the consumer/survivor/ex-
patient movement.
• The World Health Organization states that community mental health
services are more accessible and effective, lessen social exclusion,
and are likely to have less possibilities for the neglect and violations
of human rights that were often encountered in mental hospitals.
• However, WHO notes that in many countries, the closing of mental
hospitals has not been accompanied by the development of
community services, leaving a service vacuum with far too many not
receiving any care.

9. COMMUNITY PSYCHIATRY OUTSIDE INDIA

10. DEVELOPMENT IN THE UNITED STATES
• The era of so called moral treatment of the mentally ill lasted from
the American Revolution until mid-19th century, bolstered by such
people as Benjamin Rush.
• The influence of Philippe Pinel, in France and William Tuke, in Great
Britain began the era of moral treatment in Europe.
• The formation of Association of Medical Superintendents in 1844
heralded the transition from the era of moral treatment to the
custodial era of psychiatric care.

11. DEVELOPMENT IN THE UNITED STATES
• The rise of the public hospital system in America continued
throughout the latter half of 19th Century.
• In early 20th Century (1908-1910) Clifford Beers along with William
Jones and Adolph Meyer furthered the mental hygiene movement and
led in 1909 to the National Committee for Mental Hygiene in New
York.
• Meyer advocated many of the components of modern community
psychiatry, including attention to socio-cultural influences, after core,
preventive efforts, integrated programs and public education.

12. DEVELOPMENT IN THE UNITED STATES
• DEINSTITUTIONALIZATION –
– Federal legislation was important to the movement towards
deinstitutionalization.
– The U.S. Public Health Service has formed the Division of Mental Hygiene
in 1930s.
– The National Mental Health Act 9 of 1946 changed this division to the
National Institute for Mental Health (NIMH).
– The NIMH, founded in 1949 was pivotal in funding essential health
research for developing the mental health field

13. DEVELOPMENT IN THE UNITED STATES
• THERAPEUTIC COMMUNITY –
– Maxwell Jones advocated a new concept of therapeutic community.
Though essentially it was a British experiment, it was widely accepted in
the U.S.
– Before the advent of the concept of therapeutic community, the dominant
forms of psychiatric care were isolation and quarantine.
– The essential features of the therapeutic community concept were
patient's participation in decision making, collective responsibility for
ward events, a multi-disciplinary staff and a belief in the rehabilitative
potential of the environment.
– The movement was essentially psychodynamic and anti-authoritarian.
– The Menninger clinic established the first day hospital and the Fountain
House began an ex-patient social rehabilitation club in New York.

14. DEVELOPMENT IN THE UNITED STATES
• COMMUNITY MENTAL HEALTH SERVICES ACT –
– In 1963, the Community Mental Health Services Act was passed by U.S.
Congress.
– It called for the construction of Mental Health Centres in different
geographic catchment areas.
– These centres provide in-patient care, outpatient care, partial
hospitalization, emergency care, consultation, education services; follow
up care and transitional housing.

15. DEVELOPMENT IN THE UNITED STATES
• CURRENT ERA –
– From 1963, when the legislation was passed to the present, the number
of Community Health Centres has grown to about 800 serving 54% of U.S.
Population.
– With the development in community psychiatry movement, different types
of community residences have come up. These are:
1. Group home.
2. Personal Care Home.
3. Foster home.
4. Natural Family Placement.
5. Satellite Housing and
6. Independent Living.

16. DEVELOPMENT IN THE UNITED STATES
1. GROUP HOME –
– Group homes are residential facilities providing community care for a
group of patients.
– Living in the same building are staff who supervise a program that uses
group processes for psychosocial rehabilitation.
2. PERSONAL CARE HOME –
– Is a residence run by a proprietor unrelated to the residents.
– It serves 4 or more adults who are mildly or moderately disturbed.
– The program focus is on maintenance of current level of functioning.

17. DEVELOPMENT IN THE UNITED STATES
3. FOSTER HOME –
– Is a full time residential care program provided by a family unit, living in
its own home, for a small group of clients, unrelated to the family.
– The program focus is on treatment based on the family model.
4. NATURAL FAMILY PLACEMENT –
– This type of set up is mainly present in certain Scandinavian countries.
– Here the patient lives with the immediate family or relatives and these
families receive subsidies to facilitate such patients.

18. DEVELOPMENT IN THE UNITED STATES
5. SATELLITE HOUSING –
– This refers to semi-independent living arrangements in which one to four
patients occupy apartments or houses scattered in the community.
– The level of impairment ranges from mild to moderate.
– Patients placed in these settings are usually expected to do their own
cooking and housekeeping.
6. INDEPENDENT LIVING –
– Encourage autonomy and patients live independently.

19. DEVELOPMENT IN THE UNITED STATES
• In 1977, the National Institute of Mental Health (NIMH) initiated
its Community Support Program (C.S.P.). The C.S.P.'s goal was to shift the
focus from psychiatric institutions and the services they offer to
networks of support for individual clients. The C.S.P. established the ten
elements of a community support system listed below:
– Responsible team
– Residential care
– Emergency care
– Medicare care
– Halfway house
– Supervised (supported) apartments
– Outpatient therapy
– Vocational training and opportunities
– Social and recreational opportunities
– Family and network attention

20. DEVELOPMENT IN THE UNITED STATES
Morrissey & Goldman, 1984; Goldman & Morrissey, 1985

21. THE ITALIAN MOVEMENT
• The Italian movement is of particular importance because of its
influence over the development of Community Psychiatry in the rest
of the world.
• During the 1970's the Italian alternative psychiatric movement led a
struggle against traditional psychiatric ideology - such struggle
resulted in progressive dismantling of mental hospitals and in
complete reorganization of psychiatric services.
• The strict division of wards according to sex was replaced by mixed
wards. In addition, small groups of patients were formed and using
flats, set up the first family homes. They had their own rooms and
furnishing, and they could go shopping and cook.

22. THE ITALIAN MOVEMENT
• Between 1975 and 1977 the first 6 centres for mental health were
opened in the town. All wards had already lost the characteristics of
a mental hospital. By 1980 the centres for mental health reached
satisfactory working conditions.
• In the September of 1980, the administration confirmed the end of
the Mental Hospital.
• This movement was widely applied in Northern Italian regions than in
Southern regions and in large metropolitan areas.

23. THE ITALIAN MOVEMENT
• For example in Naples City, the first immediate effect of the reform
was the drastic reduction of hospital beds. Hence the beds
availability turned out to be insufficient to meet the demands for
emergency admission, which was quite high.
• This resulted in many admission requests being rejected without the
provision of any alternative service for these patients.
• As a result of these setbacks, at present in Italy, Psychiatric
hospitals were reopened and are working simultaneously with
community Mental Health Services.

24. DEVELOPMENT OF COMMUNITY PSYCHIATRY IN INDIA

25. INTRODUCTION
• The Western concept of Community Psychiatry is in short, the
extension of a wide mental health infrastructure already in existence.
• The development of the mental health services in India shows
interesting trends over the last 45 years.
• The initial emphasis was on mental hospitals, which shifted to setting
up of the general hospital psychiatry units - as suggested by The
Bhore Committee (1946), which later shifted to a community program.

26. INTRODUCTION
• It is at present considered as a movement or plan to provide basic
mental health care, to a majority of the population, in a reasonable
time-frame, with minimum resources.
• In other words, it can be said that the attempt is to extend the
services to the periphery, simultaneous to the development of
professional infrastructure.
• This innovation is interesting in that, the path for delivery of mental
health programs is through the 'primary health centres' (PHC) and by
integration with general health services.

27. HISTORY
• The origins of community psychiatric movement in India can be
traced back to a number of meetings of the Indian Psychiatric
Society (IPS).
• Notable among these is the first conference of Superintendents of
Mental Hospitals at Agra in 1960.
• As early as in 1964, Satyanand D and Hussain SE, conducted
psychiatric outdoor clinics at 4 villages in Haryana.
• They also gave lectures on positive mental health to school teachers,
block development officers staff, panchayat officers etc.

28. HISTORY
• The other significant developments are the Madurai Conference on
priorities in Mental Health Care held in 1971, the WHO Workshop on
community Action for Mental Health Care at Bangalore in 1973 and a
number of similar workshops at Wardha, and Trivandrum.
• Notable among these are the programs to develop models of rural
psychiatric services at Raipur Rani near Chandigarh and Sakalawara
near Bangalore.

29. HISTORY
• These initial attempts have been taken up in a bigger way by the Severe
Mental Morbidity study of ICMR since 1979, where the feasibility of
training health personnel was examined at 4 centres namely Bangalore,
Baroda, Calcutta and Patiala.
• All these studies and experiences have made it possible to consider
launching community psychiatry programs in a bigger scale.
• The outcome of all these developments is the National Mental Health
Programme (NMHP) which was recommended for implementation by the
Central Council of Health and Family Welfare in its meeting on 18-20
August 1982.

30. OBJECTIVES OF NMHP
• The objectives of the program are
1. To ensure availability and accessibility of minimum mental health care
for all
2. To encourage application of mental health knowledge in general health
care
3. To promote community participation in the mental health services
development and to stimulate efforts towards self-help in community
• For implementation of these objectives, the NMHP suggested certain
approaches like integrating the basic mental health care into general
health services, proper distribution of resources and training of
General Medical practitioners, paramedical staff, multipurpose health
workers and anganwadi workers.

31. PROGRESS SINCE 1982
• NMHP among other activities has conducted various workshops for
state level planners and administrators, state level workshops for
psychiatrists in various states and workshops on the role of clinical
psychologists in 1986.
• Pilot programs of training of Health Personnel have now been
initiated in almost all the states and union territories.
• In March 1988, a workshop on Mental Hospitals was held which
recommended development of greater interactivity between hospital
and community.

32. PROGRESS SINCE 1982
• The NMHP was extensively reviewed in June 1988 and as a result, the
National Advisory Group on Mental Health (NAGMH) was formed in
August 1988.
• The NAGMH has recommended among other things - to provide
mental health care as part of the overall health, welfare and
education services.

33. THE RANCHI EXPERIMENT
• As a part of NMHP objectives a training program in mental health was
conducted at Central Institute of Psychiatry, Ranchi, for general
physicians including one or two medical officers working in the
Directorate of Health Services of each North-Eastern States.
• These trained personnel were later able to provide medical care and
also could organize similar programs in their respective states.

34. OTHER ORGANISATIONS
• In addition to the NMHP, there are some voluntary organizations and
NGOs in the area of mental health rendering good service on non-
profit basis.
• Schizophrenia Research Foundation (India) (SCARF) is one among
them which is running a community psycho-educational program in
Tirubalom and Katpadi of South Arcot District since July, 1987.

37. CONTRIBUTION OF INDIAN MHA ACT 1987
• It has discarded the outdated concepts of custodial care and
segregation of mental patients from the community.
• For the first time, it brought out judicial safeguards for patients‘
rights.
• Has introduced humanitarian considerations to prevent indignity or
cruelty to the mentally ill.
• Has simplified the procedures for admission and discharge of
patients and it has tried to reduce the stigma attached to mental
illness by bringing it at par with other physical illness.

38. PROS AND CONS OF COMMUNITY PSYCHIATRY
MOVEMENT IN INDIA

39. PROS
• Shortens 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.
• Helps transition from hospital to community: A short stay in a
suitable community residence will help long-term institutionalized
patients in regaining the skills and capacities required to cope with
everyday situations.

40. PROS
• 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.
Two such important studies are conducted in Friern and clayburg
hospitals in North London. In another study in Italy, cost of one year
community psychiatric care was found to be 43% of that in a mental
hospital.

41. PROS
• Increased Acceptance: With the advent of community psychiatry,
attitudes of the people have changed towards greater acceptance of
the 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.

42. PROS
• 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.

43. 4 P’S OF EFFECTIVE COMMUNITY PROGRAMME
• Political or planners' commitment
• Professional commitment
• Progress in mental health know-how and
• Participation of the Community.

44. CONS
• Reinstitutionalization: "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.

45. CONS
• Manpower Problems: The misdistribution 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: 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.

46. INITIATIVES BY INSTITUTE OF MENTAL HEALTH
• Community Psychiatry Projects
Epidemiological study of psychiatric morbidity in an industrial population undertaken
at Kalpakkam atomic energy center in the year 1994-95
• National Mental Health Program
Training of trainers program 1996, a govt. of India sponsored program
• District Mental Health Program
Institute of Mental Health has been selected as a Nodal centre for this project by
Government of India. The project is being implemented at Trichy. It is a five-year project
commenced from 1997. The District Mental Health Program, Trichy implemented by Institute
of Mental Health is emerging as a model community program for the country.

47. INITIATIVES BY INSTITUTE OF MENTAL HEALTH
• Out Reach Services of Institute of Mental Health
1. Counseling & Rehabilitation services at Seva Sadan and YWCA.
2. Community services at
• District Mental Health Program at Trichy
• Psychiatric Health Centre, Poonamallee
• Beggars Care Camp, Melapakkam
• Half way Home for women YWCA

48. REFERENCES
• World Health Organization press release (2007) Community mental
health services will lessen social exclusion, says WHO.
• Seshi Kumar D. The community psychiatry movement: pros and cons.
AP J Psychol Med 2011; 12(2):73–8.
• Mosher, L., Burti, L. (1989). Community Mental Health: Principles and
Practice. New York: W. W. Norton & Company.
• http://www.tnhealth.org/directorate/imh.htm

49. THANK YOU