Community mental health
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COMMUNITY MENTAL HEALTH. Professor Moruf Adelekan Royal Blackburn Hospital Blackburn United Kingdom. Definitions.

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COMMUNITY MENTAL HEALTH

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Community mental health

COMMUNITY MENTAL HEALTH

Professor Moruf Adelekan

Royal Blackburn Hospital

Blackburn

United Kingdom


Definitions

Definitions

  • Community mental health services (CMHS), also known as Community Mental Health Teams (CMHT) in the UK support or treat people with mental disorders in a domiciliary setting, instead of a psychiatric hospital setting

  • The array of community mental health services vary depending on the country in which the services are provided.

  • Could include:

    • Supported housing with full or partial supervision (including half-way houses)

    • Psychiatric wards of general hospitals

    • Local primary care medical services

    • Day centres or clubhouses

    • Community mental health centres

    • Self-help groups


Definitions contd

Definitions (contd.)

  • The services could be provided by:

    • Government organizations

    • Mental health professionals, including specialized teams providing services across a geographical area (e.g. Crisis Teams, Assertive Outreach Teams; Early Psychosis Teams)

    • Private or charitable organizations

    • Peer support groups

    • Psychiatric consumer movements

    • The WHO states that community mental health services:

      • Are more accessible and effective

      • Lessen social exclusion

      • Are likely to have less possibilities for the neglect and violations of human rights


Global issues on mental health

GLOBAL ISSUES ON MENTAL HEALTH

  • VITALLY IMPORTANT ISSUES FOR NATIONS: MORBIDITY, MORTALITY AND HUGE ECONOMIC BURDEN

  • FACTORS

    • Established biological and generic reasons

    • Current disruption of social fabric as a result of changing political scenario, violence and terrorism which affect the psyche of millions


Who statements

WHO STATEMENTS

  • 450 millions people in the world suffer from a mental and behavioural disorder

  • 33% of the years lived with disability (YLD) are due to neuropsychiatric disorders

  • Unipolar depressive disorders alone lead to 12-13 years of YLD and rank as 3rd leading contributor to global burden of diseases

  • 4 of the 6 leading causes of YLD are due to neuropsychiatric disorders like depression, alcohol use disorders, schizophrenia and bipolar affective disorder

  • 150 million suffer from depression at any point in time

  • Nearly one million commit suicides yearly

  • 25 million suffer from schizophrenia

  • 38 million suffer from epilepsy

  • 90 million suffer from alcohol and drug use disorders


The journey to community mental health

The journey to Community Mental Health


Community mh programmes in the uk

COMMUNITY MH PROGRAMMES IN THE UK

  • CRISIS RESOLUTION AND HOME TREATMENT TEAM

  • ASSERTIVE OUTREACH TEAM

  • EARLY INTERVENTION FOR PSYCHOSIS TEAM


Crisis resolution and home treatment teams

CRISIS RESOLUTION AND HOME TREATMENT TEAMS

  • Who is the service for?

    • Adults between 18-85 yrs with severe mental illness, with an acute psychiatric crisis of such severity that, without the involvement of the CRHTT, hospitalisation will be necessary

    • In every locality, there should be flexibility to decide to treat those who fall outside this age group where appropriate

  • What is the service intended to achieve?

    • Treatment in the least restrictive environment

    • An alternative to inpatient care

    • Gate keeping role: assessment and referral to appropriate services

    • Multidisciplinary 24/7 service for those who need service


Crisis resolution and home treatment teams1

CRISIS RESOLUTION AND HOME TREATMENT TEAMS

  • What does the service do?

    • Assessment: screening for appropriateness; referral to other services to ensure continuity of care

    • Production of a Care Plan for every patient: number of visits and level of input, discharge planning from the beginning

    • Intervention: nursing, medical and social services

    • Frequent contacts visits throughout the crisis

    • Ongoing risk and needs assessment

    • Throughput service

    • Medications

    • Practical help with basics of daily living

    • Family/carer support

    • Relapse prevention

    • Crisis plan

    • Respite

    • Links with in-patient services

    • Resolution


Management of service and operational procedures

Management of service and Operational Procedures

  • Model of service delivery

    • A discrete, specialist team

    • Staff members main responsibility is to manage people in crisis

    • Adequate skill mix within the team to provide all the interventions listed

    • Strong links with other MH services and a good general knowledge of local resources

  • Formation of service

    • Local epidemiology should be undertaken initially

    • Audit of pathways of care, current service provision

    • Use the information obtained to develop the implementation plan

    • A project manager should be employed to oversee the formation of the team


Assertive outreach teams

ASSERTIVE OUTREACH TEAMS

  • Developed from the US Assertive Community Treatment (ACT)

  • Characterised by:

    • Small caseload size with a focus on severe mental illness alone

    • A blurring of the traditional roles of mental health professionals

    • Emphasis on sustained efforts to follow-up previously poorly compliant patients actively

    • Low patient-staff ratios (10:1 up to 15:1)

    • Frequency of contact, which often takes place at the patient’s home, is high, is adjusted to need , and ranges from daily to once a fortnight, but characteristically is about twice a week

    • Intended to to be easily accessible at times of crisis

    • Not time-limited


Assertive outreach teams contd

ASSERTIVE OUTREACH TEAMS (contd.)

  • AOT interventions concentrate on

    • Developing long-term therapeutic relationships with previously hard-to-engage patients

    • Intense monitoring of symptoms and subsequent rapid adjustment of treatments if required

    • Medication may be administered by staff daily if needed

    • Non-medical interventions include:

      • Intensive emotional and/or practical support

      • Specific psychological interventions, such as problem solving or cognitive behavioural therapy

      • Family work and support for carers


Early intervention for psychosis services

EARLY INTERVENTION FOR PSYCHOSIS SERVICES

  • Around one in 100 young people will develop a potentially serious mental health condition (psychosis) in their teens or 20s. With early treatment, most people will make a full recovery.

  • The Early Intervention for Psychosis Service (EIS) is for young people aged 14 to 35 years old.

  • The MH professionals are experts in assessing, treating and supporting young people in the early stages of a psychotic illness.

  • They assess young people and can offer support for up to three years. This may include social, psychological and emotional support, as well as medical input.


Early intervention for psychosis services1

EARLY INTERVENTION FOR PSYCHOSIS SERVICES

  • Early warning signs include:

    • Constant tiredness

    • Withdrawal from family and friends

    • Feeling uneasy

    • Feeling depressed and anxious

    • Becoming suspicious, losing trust in people

    • Seeming muddled, losing concentration

    • Saying and believing things that don't make sense


Early intervention for psychosis services2

EARLY INTERVENTION FOR PSYCHOSIS SERVICES

  • The approaches are:

    • Early detection through education of the community, anti-stigma campaigns, and training of professionals

    • In an acute phase, the emphasis is on multidisciplinary assessment

    • A broader approach to detecting psychosis rather than on the narrow diagnostic criteria of schizophrenia

    • Initiating treatment in the community with as low a dose of atypical antipsychotics as possible

    • Emphasis on therapeutic engagement


Mental health services in nigeria

MENTAL HEALTH SERVICES IN NIGERIA

  • In 2006, Professor Oye Gureje led a team of researchers to conduct an assessment of the mental health system in Nigeria using the WHO “Assessment Instrument for Mental Health Systems” (WHO-AIMS)

  • The study selected 6 cities (states) covering the 6 geopolitical zones: Lagos (SW), Calabar (SS), Enugu (SE), Kaduna (NC), Maiduguri (NE) and Sokoto (NW).

  • The authors cautioned that these states represent only 17% of the Nigerian population. Yet, their findings gave a very good indication of the state of affairs in Nigeria.

  • Federal Psychiatric Hospitals are located in all of these cities


General findings of the aims survey

General findings of the AIMS survey

  • Mental health services are quite limited

  • Existing MH policy formulated in 1991 has not been updated

  • No comprehensive MH legislation currently exists in the country

  • There were no family or patient associations in these areas and there are no mechanisms to protect patients rights

  • There was no provision for interactions between mental health providers and primary care staff

  • No desk exist in the ministries at any level for mental health issues

  • Only 3.3% of government expenditures on health is earmarked for mental health, and over 90% of this to MH hospitals


Aims survey human resources

AIMS Survey: Human Resources

  • Psychiatrists42 (0.15 per 100,000)

  • Other medical doctors135 (0.49 per 100,000)

  • Nurses659 (2.41 per 100,000)

  • Psychologists20 (0.07 per 100,000)

  • Social workers34 (0.12 per 100,000)

  • Occupational Therapists 15 (0.5 per 100,000)

  • Other health or mental HWs2200 (8.03 per 100,000)


Aims survey bed distribution in facilities

AIMS Survey: Bed distribution in facilities


Aims survey community based facilities

AIMS survey: Community based facilities

  • Community-based psychiatric inpatient services

    • 5 in the six states with 124 beds in total

    • Schizophrenia and related disorders (43%) and mood (affective) disorders (25%)

    • Patients spend on average 21 days on admission

  • Community-based residential services

    • Only one, in Lagos with 10 beds

    • Run by a religious mission for rehabilitation of patients with drug problems

    • Average no of days spent in facility is 290


Community mh in developing countries the reality

COMMUNITY MH IN DEVELOPING COUNTRIES: THE REALITY

  • MENTAL HEALTH LESS PRIORITY THAN PHYSICAL HEALTH

  • CULTURAL CONCEPTS ABOUT MENTAL ILLNESS/STIGMA

  • USE OF ALTERNATIVE CULTURALLY ACCEPTABLE Rx MODELS

  • ABSENCE OF ORGANIZED SOCIAL WELFARE NETWORK

  • LITTLE RESOURCES FOR PREVENTIVE OR POSITIVE MH

  • OTHER MILITATING FACTORS:CIVIL STRIFE AND VIOLENCE IN SOME SOCIETIES;POLITICAL INSTABILITY; CORRUPTION; GENDER INEQUALITY AND ABSENCE OF BASIC HUMAN RIGHTS


How to set up a cmh service in a developing country

HOW TO SET UP A CMH SERVICE IN A DEVELOPING COUNTRY

  • NEEDS ASSESSMENT: EPIDEMIOLOGY, RESOURCES INCLUDING FINANCIAL, HUMAN, PHYSICAL, COMMUNITY

  • A STRONG AND WELL FUNDED POLICY FRAMEWORK

  • TEACHING AND TRAINING: PHC WORKERS; GPs; OTHER HEALTH WORKERS

  • SHOULD CMH REMAIN IN PSYCHIATRY OR COMMUNITY HEALTH

  • ESTABLISH PARTNERSHIP WITH PRIVATE ORGANISATIONS (NGOs; CBOs etc)

  • ? ESTABLISH PARTNERSHIP WITH TRADITIONAL HEALERS AND RELIGIOUS GROUPS

  • USE THE MEDIA (PAPERS, RADIO, TV) TO EDUCATE THE MASSES TO REDUCE STIGMA


Critical steps in setting up the service

CRITICAL STEPS IN SETTING UP THE SERVICE

  • ASSESS THE CURRENT NEEDS OF A DEFINED POPULATION

    • Defined as specific types of impairments, disabilities and handicaps

    • Also incidence, prevalence and severity of morbidity

  • SET GOALS

    • Ensures that resources are allocated to defined priorities related to identified needs

    • Specific, Measurable, Accessible, Realistic and Time limited

  • ALLOCATE RESOURCES

    • To enable achievement of set goals in the most efficient manner

    • Set priorities and use all available resources (including hidden community resources)

  • IMPLEMENT

    • Train staff on evidence-based therapeutic that can address the needs

    • Ensure right staff mix and that the right person performs the right task

  • REVIEW PROGRESS

    • Protocols should be developed to measure clinical and administrative progress

  • ASSESS OUTCOME

    • Perhaps annually

    • Check if goals have been achieved and needs met?

    • Check efficiency of goal setting and resource allocation


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