COMMUNITY PSYCHIATRY

&n= bsp; &nb= sp; &nbs= p; = ; = =20 Dr.Aparajeeta=20 Baruah

&n= bsp; &nb= sp; &nbs= p; = ; = =20 Associate Professor of Psychiatry

&n= bsp; &nb= sp; &nbs= p; =20 &n= bsp; &nb= sp; LGB=20 Regional Institute of Mental Health,

&n= bsp; &nb= sp; &nbs= p; = ; = =20 Tezpur, Assam.

Introduction:- =

=20 =20 During the second half of the 20^th century and = specially in=20 its last decade, mentally ill people have been moved out of the relative = simplicity of the large Institution with its clear structure and=20 hierarchies and into the = community=20 which may be regarded as a third Psychiatric revolution. Prior to that Phillippe Pinel = in France,=20 William Tuke in Greet Britain, Dorothea Dix in Columbia (USA) tried to = provide=20 moral treatment for the mentally sick person by treating them in the=20 Asylums.

=20 =20 In 1909 Adollph Meyer with William Jones and Beers started the = Mental=20 Hygiene movement in USA.

=20 =20 During World War II, Thomas Salmon first started the short term = model for=20 crisis intervention for soldiers emphasizing immediate treatment close = to the=20 stressful situation. = Thereafter=20 Social Science Researchers like Maxwell Jones advocated the concept of=20 Therapeutic Community. = The=20 Menninger Hospital first established the first day hospital.

=20 =20 The advent of the first anti psychiatric drug Chlorpromazine has = led to=20 the deinstitutalization of many of the mentally sick persons to start = Community=20 Psychiatry programme. =

Definition of Community = Psychiatry=20 (Oxford Textbook of Community Psychiatry Thornicroft and = Szmukler)

=20 =20 Community Psychiatry comprises the principles and practices = needed to=20 provide mental health services for a local population by =96

(i) = ; =20 Establishing population based needs for treatment and = care.

(ii) = ; =20 Providing a service system linking a wide range of = resources of=20 adequate capacity, operating in accessible locations and ,

(iii) = ; =20 Delivering evidence based treatment to people with = mental=20 disorders.

=20 The American Heritage = and=20 Stedman=92s Medical Dictionary 2^nd edition defines = Community=20 Psychiatry as the discipline focusing on detection, prevention, early = treatment=20 and rehabilitation of emotional and behavioural disorders as they = develop in a=20 community.

=20 Thornicroft and Tansella (1999) defined a Community based = mental=20 health service is = one which=20 provides a full range of effective mental health care to a defined = population=20 and which is dedicated to treating and helping people with mental = disorders, in=20 proportion to their suffering or distress, in collaboration with other = local=20 agencies.

Background = information:

=20 =20 Mental disorders have been viewed as a curse, as a result of bad = deeds in=20 the lifetime or in the past, or as an infliction caused by others for=20 revenge. In India, even = in the=20 Vedic age of Charaka and Sushruta, efforts were made to under stand and = classify=20 mental disorders. There = had been=20 mention of these as =91Unmads=92 in the Charaka Samhita. In Ayurveda there was mention = of=20 management of the mentally ill by religious rituals, prayers and herbal=20 medicines like Rowlfia Serpentina ,Cannabis, and Alcohol along with = restriction=20 of certain foods.

=20 =20 Organized mental health care in the form of Mental Asylum was = started in=20 India by the British in the year 1745 in Bombay. As such it was not for proper = treatment=20 of the mentally ill persons, rather they were kept in the asylum = isolated, so=20 that they could not disturb the normal people in the society. The set up was inhumane as the = patients=20 were kept in the asylum like the convicts in a jail. There were however public = movements in=20 France, Britain and the United States of America against such ill = treatment and=20 moral treatment was subsequently started which included human care, = avoiding=20 physical restraints, better staff patient interaction and an open door=20 system.

=20 =20 In 1909, Adolf Meyer advocated management of mentally ill = patients=20 outside the institutions and proposed a comprehensive =91community = mental health=20 approach=92 in which psychiatrists, family physicians, police, teachers = and social=20 workers would work together to organize primary, secondary and tertiary = preventive=20 measures in the community.

&nbs= p; =20

=20 The community programme = in the real=20 sense is a peoples programmes.

=20 =20 In 1952, the committee on mental health of the World Health = Organization=20 recommended components for a community mental hospital which included = outpatient=20 treatment, part time service, rehabilitation, research and community=20 education.

=20 =20 In the USA the community mental health movement had its rise and = fall=20 between 1950s and 1980s. = There were=20 a very large numbers of mental patients in the state hospitals. In New York City itself there = were=20 91,000 beds for mental patients. = In=20 1963, President J. F. Kennedy passed a resolution and the US congress = passed the=20 community mental health centre = act=20 to establish community mental health centers to offer care to the = patients=20 discharged from the mental hospitals. =20 These centers provided outpatient as well as inpatient care, = emergency=20 services, crises management, community consultation and education. These centers had = multidisciplinary team=20 consisting of psychiatrists, clinical psychologists, psychiatric social = workers,=20 occupational therapists involved in the service, and linkage were = established=20 with schools, welfare workers and agencies and families of the mentally = ill in=20 the community. By this = approach=20 there was effective management and the total number of mental hospital = beds of=20 5,60,000 in 1955 was brought down to 61,000 in 1992.

=20 =20 In spite of all such community approach movement in other parts = of the=20 globe, in India, the situations remained same and new mental hospitals = were=20 established till 1966; and number of hospitals from 17 in 1946 rose to = 48 in=20 1992. But barring a few = exceptions,=20 the conditions of most of these hospitals remained unsatisfactory = because of=20 paucity of fund, lack of mental health professionals, lack of training = of the=20 existing staff and poor administration. =20 The general hospitals in 1960s and 1970s opened up psychiatric = department=20 in many places with inpatient facilities. =20 The Mudaliar committee in 1962 envisaged that within the next 10 = years=20 psychiatric units would be set up in all the district hospitals of the=20 country. Even now, = majority of the=20 districts except in Kerala, Karnataka and Tamil Nadu, do not have such=20 units. In Assam, out of = 23=20 districts there are only 5 district hospitals with psychiatric = units. Such unit in the district = hospitals=20 would have the advantage over the mental hospitals because they would be = easily=20 accessible, approachable without stigma, would facilitate outpatient = treatment=20 for minor mental health problems and would help in integration of = psychiatric=20 services into the general health system.

The=20 inspiration for the community mental health movement in India comes from = the=20 sources like:

1. The adoption of community mental = health=20 programme by USA in 1963 when the American Psychiatrists realized about = Social=20 Breakdown Syndrome resulting from long term hospitalization.

2. The realization of the fact that = Institution=20 based psychiatry through trained professionals is very expensive and = countries=20 like India do not have sufficient manpower and facilities to deliver = Mental=20 Health services through conventional method.

3. The discovery in poor countries like = India that=20 para professional ]s and non professionals too can deliver reasonably = adequate=20 mental health care after undergoing =20 simple and short innovative training.

Psychiatric Unit in General=20 Hospitals =96

&nbs= p; =20 As a part of deinstitutionalization, many part of the country = established=20 General Hospital Psychiatric units, the first one was set up in 1933 at = the R.G.=20 Kar Medical College at Kolkata. Most of such units came up after 1960's = after=20 advent of antipsychotic drugs. = In=20 the west, the GHPU were created to attend to Neuroses and psychiatric = illness,=20 but those in India handled all kinds of psychiatric problems. This gave a new sense of = confidence to=20 both the Psychiatrists and patients.

=20 =20 In India, however the pathetic scenario continued for a long = time. Queen Victoria of England, in = 1920=20 passed an order to convert all the mental asylums as mental hospitals = and the=20 order was carried out in India also. =20 The conditions of the asylum and the administrative functions = remained=20 same with the same design for detention and safe custody without regard = for=20 curative treatment. The = existing=20 accommodation was also not adequate for the number of patients = kept. At the time of independence, = there was=20 only one mental hospital bed for 40,000 population in India, whereas in = England=20 it was one for 300 population.

As = per=20 recommendation of the Bhore Committee set up in 1946, the National = Institute of=20 Mental Health and Neurosciences (NIMHANS) was established in Bangalore = in 1954=20 for training of mental health professionals. In 1957, Dr. Vidya Sagar, the = then=20 Superintendent of Amritsar Mental Hospital started involvement of family = members=20 in treatment of the patients by keeping the patient with family members = in open=20 tents pitched in the hospital campus. =20 The result was very much satisfactory as the patients recovered = rapidly=20 and could go back home with the family members. The family members also could = understand=20 the procedures to tackle the problems of the patients and relapse rate = was low.=20 Based on the success of this approach NIMHANS of Bangalore and Christian = Medical=20 College of Vellore established family wards in their hospitals. This happened before the era = of major=20 tranquilizers.

In = the 1970s=20 another approach was considered for mental health care. The existing centers offering = mental=20 health care served only 20% of the population and that too in urban = areas only,=20 whereas 70% of the total population used to live in rural areas. All the epidemiological = studies=20 conducted in India revealed that mental morbidity was almost same in = rural and=20 urban areas. People could = not or=20 did not make use of the available services because of the following=20 reasons:-

1. = ; =20 Ignorance about the available services

2. = ; =20 Existing belief that mental disorders are caused by = evils=20 spirits or black magic or due to bad deeds.

3. = ; =20 Lack of knowledge regarding modern method of treatment=20 available

4. = ; =20 Long distance to the centers offering services

5. = ; =20 Social stigma

6. = ; =20 Lack of financial resources to meet the cost of = transport,=20 accompanying persons and other costs. =20

A = primary care=20 approach was therefore necessary to cover the rural population through = the=20 primary care centers available in rural areas. In 1975, the World Health = Organization=20 (WHO) established a report on organization of mental health care in = developing=20 countries. In the report, = WHO=20 strongly recommended the delivery of mental health services through = primary care=20 system as a policy for the developing countries. Efforts were made to = implement the=20 primary care approach in the country. =20 One center was established by the Post Graduate Institute of = Medical=20 Education and Research (PGIMER), Chandigarh, in 1975 at Raipur Rani = Block of=20 Ambala district of Haryana and another by NIMHANS, Bangalore, in 1976 at = Sakalwara village in Karnataka. = The=20 Central Institute of Psychiatry Ranchi first started Rural Mental Health = Center=20 in 1964. A workshop at = Madras in=20 1971 organized by Indian Psychiatric Society recommended that adequate = training=20 in mental health should be imparted to increase the workforce including = General=20 practitioner, Medical Officers, Nurses, health visitors, midwives, = social=20 workers ,gramsewaks and voluntary organization.

The NIMHANS Crash=20 Programme

&nbs= p; =20 At the initiative of the Director Dr. R. M. Varma and Dr. Karan = Singh,=20 Minister of Health in the Central Govt. a crash programme for community = based=20 mental health was introduced at NIMHANS along with the starting of = Community=20 Psychiatry Unit in October 1975.

=20 The following experimental programme was launched by this unit = -

=20 1.=20 Primary Health Center based rural mental health programme - = training of=20 multipurpose workers and PHC doctors were organized.

=20

=20 2.=20 General Practitioner (GP) based urban, mental health = programme - a manual was prepared to train GPS = in=20 treating common mental health disorders.

=20 3.=20 School Mental Health programme - where teachers were trained to = diagnose children with emotional = problems with=20 counseling.

=20 4.=20 Home based follow up of psychiatric patients where nurses were = trained to=20 follow up patients by home visits.

&nbs= p; =20

=20 5.=20 Psychiatric camps were organized like other health check up = camps.

.A = feasibility=20 study was conducted from 1975 to 1980 in both the centers of NIMHANS and = PGIMER=20 i.e. Sakalwara and Raipur respectively. The study revealed that;

=20

1. = ; =20 Majority of the mentally ill Epileptics and mentally = retarded=20 children remained untreated in spite of being nearer to a well = established=20 Psychiatric hospital.

2. = ; =20 All the families of the affected had approached = traditional=20 healing centers and local healers but in vain.

3. = ; =20 Majority of the patients with psychoses and epilepsy = were ill=20 for more than two years.

4. Key informants, health workers and = others could=20 easily identify and report.

5. A limited numbers of drugs like = Chlorpromazine,=20 Trifluperazine, Diazepam, Fluphenazine decanoate, Imipramine, = Phenobarbitone,=20 Trihexyphenidyl were sufficient to manage almost all cases.

6. Most of the Psychotics improved with = medication=20 and were rehabilitated within their villages. Improved patients were = accepted to=20 join the mainstream of life without stigma.

7. Medical and non-medical workers were = able to=20 learn to manage priority mental disorders in short term courses.

Considering the=20 various factors NIMHANS and other institutions developed other = alternatives to=20 institutional care, such as :-

=D8 = ; =20 Extensive use of outpatient services.

=D8 = ; =20 Extension programme by satellite clinics.

=D8 = ; =20 Domiciliary care programme through trained = paramedical=20 staff.

=D8 = ; =20 Organizing care through private general=20 practitioners.

=D8 = ; =20 Training of school teachers in mental healthcare = and=20 promotion of mental health care through schools.

=D8 = ; =20 Involvement of ICDS personnel in child mental = health=20 care.

=D8 = ; =20 Training of non-medical volunteers.

=D8 = ; =20 Training of college student volunteers.

=D8 = ; =20 Training of village leaders

=D8 = ; =20 Student enrichment programme.

=D8 = ; =20 Involvement of non governmental voluntary=20 organizations.

National=20 Mental Health Programme ( = 1982=20 ) :

In = 1982, the=20 health administration in India recognized the need for mental health = care and=20 the National Mental Health Programme 1982 (NMHP) was launched all over = the=20 country. The main = objectives of the=20 programme are =96

1. = ; =20 Prevention and treatment of mental and neurological = disorder=20 and their associated disabilities and to promote community participation = in the=20 organization of services.

2. = ; =20 Use of mental health technology to improve general = health=20 services.

3. = ; =20 Applications of Mental Health Principles in total = National=20 development to improve quality of life.

=20 The approaches to achieve these objectives are =96

1. =20 Diffusion of mental health skills to the periphery of = the=20 health service

=20 systems.

2. =20 Appropriate allotment of task in mental health care for = different levels of health personals.

3. =20 Equitable and balanced territorial distribution of=20 resources.

4. =20 Integration of basic mental health care into general = health=20 services.

5. =20 Linkage to community development.

6. =20 Improve mental health training in all institutions = where=20 medical and paramedical workers are trained.

7. =20 Train parents and ICDS personnel in the management of = mentally=20 retarded children.

&n= bsp; =20 Thus, a decentralized program which is delivered by = non-specialist=20 medical and non-medical personnel, using simple, less expensive but effective=20 intervention technique, is recommended adhering to the following = fundamental=20 concepts :--

1. = Majority of the mentally ill do not reach the existing=20 psychiatric services.

2. = A large proportion of mental disorders as seen in the = community=20 are ambulatory, self limiting and manageable at the small medical = institutions=20 or in the community itself.

3. = Diseases are better managed if they are recognized in = the=20 initial stage, thus preventing chronicity, disability and burden on the = family=20 and society. &n= bsp; =20

Once chronicity sets in, it = would demand=20 costly and sophisticated methods of intervention and expertise for its=20 management.

In = 1995, District=20 Mental Health Programme (DMHP) was started as a component of the = National Mental=20 Health Program. The prototype was the Bellary district mental health = programme=20 in Karnataka started in 1985. = Under=20 the programme the mental health services are integrated in general = health care=20 services in the district hospitals, community health centers, primary = health=20 centers, dispensaries and sub centers by training of the staff and = providing=20 psychotropic medicines.

In = 2001, WHO=20 published the World Health Report (WHR) wherein it was identified that = =93one=20 person in every four will be affected by a mental disorder at some stage = of=20 life=94 and pointed out that psychiatric disorders are estimated to = account for=20 12% of the global burden of all diseases, yet the mental health budget = of the=20 majority of countries constitute less than 1% of their total health care = expenditures. The WHR = 2001 also=20 made ten recommendations for action.

1. = ; =20 Provide treatment in primary care.

2. = ; =20 Make psychotropic medicines available

3. = ; =20 Give care in the community

4. = ; =20 Educate the people

5. = ; =20 Involve communities, families and consumers

6. = ; =20 Establish national policies, programmes and legislation =

7. = ; =20 Develop human resource

8. = ; =20 Link with other sectors

9. = ; =20 Monitor community mental health.

10. = ; =20 Support more research

According to=20 the WHR 2001, the problem of the burden of mentally ill persons is = enormous and=20 the same is further aggravated by the lack of necessary resources. The incidence of severe mental = illness=20 has been observed 35/100,000 population. =20 In India =96

Psychiatric = beds per=20 10,000 population = &nbs= p; =20 =3D 0.3 &nbs= p; =20 (World =3D 4.36)

Number of=20 Psychiatrist per 100,000 population &nbs= p; =20 =3D 0.3 &nbs= p; =20 (World =3D 3.06)

Clinical=20 Psychologists per 100,000 population &nbs= p; =20 =3D< 0.1 &nbs= p; =20 (World=3D6.43) &n= bsp; =20 Psychiatric Social Worker per 100,000 population &nbs= p; =20 =3D <0.1 &nbs= p; =20 (World =3D 8.64)

Psychiatric=20 Nurses per 100,000 population = &nbs= p; =20 =3D <0.1 &nbs= p; =20 (World =3D 12.6)

There has=20 been some improvement in the number of available psychiatric beds at=20 present. At the national = level at=20 present there is one psychiatric bed per 20,000 population. But in Assam and the adjoining = North=20 Eastern states there is one bed per 39,000 population. The available beds in this = region are=20 not uniformly utilized by the population of the entire region because of = difficulties and long traveling distance to reach a center.

Experience = of=20 LGBRIMH, Tezpur, in Community Psychiatry:-

The=20 extension clinic established by LGB Regional Institute of Mental Health, = Tezpur=20 (LGBRIMH), at Biswanath Chariali was initially on experimental basis in = April=20 2001 as a part of Community Psychiatry programme which is at a distance = of 80=20 KM. The idea was to offer = mental=20 health care services to the population in an around Biswanath Chariali = which is=20 the sub-divisional head quarter and the population had been with = different=20 religions, races, languages, cultures and economic status. As the Institute did not have = adequate=20 manpower, the clinic had been run once in a month on a fixed day i.e on = every=20 last Friday of the month. = The venue=20 for the clinic had been the sub divisional hospital where the team = attending the=20 LGBRIMH worked for the whole day.

STATISTICS FOR LAST FIVE YEARS OF = EXTENSION=20 CLINIC BISWANATH CHARIALI

Year

New

Follow-up

Total

2001

189

252

441

2002

291

1155

1446

2003

283

1551

1834

2004

390

1980

2370

2005

420

2368

2788

Total

=20 1573

7306

8879

Number of=20 Patients

=20

The five years = observation=20 reveals the following;

1) The relapse rate = of patients=20 has come down drastically for which the revolving door system of admission to the = parent=20 Institute has been reduced.

2)Drug = compliance is noticed as all the = medicines are=20 distributed free of cost.

3)The stigma = attached in attending a mental health = centre is=20 not there as the services are rendered in the local civil hospital = itself along=20 with other general patients. Many neurotic patients previously attending = Medicine OPD are referred to the extension clinic.

4)The improved = patients are=20 helping in running the clinic successfully.

5)The attendance rate = of patients=20 at the extension clinic is growing each year which reflects the = acceptance of=20 the clinic by the community, this has indirectly brought down the rush = in the=20 parent institute itself.

= The=20 need for starting more such clinics in other areas has been felt by the = staff of=20 the Institute.

Conclusion:-

= From=20 its modest beginning in a few centres like Ranchi, Bangalore and = Chandigarh,=20 community mental health care today has gained momentum, but is still = restricted=20 to professionals and non-professionals who believe in this movement, but = even=20 today majority of the government and voluntary organization still = continue to=20 provide only clinical services, care is not taken for preventive, = promotive and=20 rehabilitative aspect of mental health. If mental health teaching and = training=20 is fully integrated in the general health education, only then the WHO=20 definition of health being not only a state of physical well being, but = also of=20 mental and social well being will be achieved in the truest sense .

References:

1.=20 Graham Thornicroft and George Szmukler

- =20 Textbook=20 of Community Psychiatry. ( 2001 )

2.=20 Harlod Kaplan & Benjamin Sadock.

=20 - Comprehensive Textbook of Psychiatry. ( 8^th ed=20 )

= Williams & = Wilkins. (=20 2005 )

3.=20 Purnima Mane, Kety Gonderia

=20 - Mental Health in India : Issues and concerns published by Tata=20 Institute of social science. ( 1993 )

&nbs= p; =20

4.=20 S.P. Agarwal .

=20 - Mental Health : An Indian Perspective ( 1946-2003=20 )

=20 Published = by DGHS=20 (Ministry of Health & Family welfare, New = Delhi

=20 =20 (2004)

5.=20 R.S, Murthy & Barbara J. Burns.

=20 - Community Mental Health Proceedings of = Indo-

US symposium NIMHANS = Publication=20 1992 ( 1^st ed )

6.=20 Department of Community psychiatry

=20 LGBRIMH, Tezpur.