Community Mental Health

Putting Policy Into Practice Globally

Graham Thornicroft, Atalay Alem, Robert E. Drake, Hiroto Ito, Jair Mari, Peter McGeorge, R. Tara, Maya Semrau, Graham Thornicroft, Atalay Alem, Robert E. Drake, Hiroto Ito, Jair Mari, Peter McGeorge, R. Tara, Maya Semrau

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9781119998655
• eBook ISBN: 9781119952145
• Edition: 1
• Topic: Medicine
• Subtopic: Anatomy

There are wide inconsistencies between, and even within, countries in how community-orientated care is defined and interpreted. The analysis presented in this book take as a starting point an evidence-based balanced care model in which services are provided in community settings close to the populations served, with hospital stays being reduced as far as possible, usually located in acute wards in general hospitals. The surprising conclusion from the research is that the same problems arise in all countries, regardless of resource status, and thus the recommendations of this book apply to mental health provision everywhere.

This book reviews the implementation of community-orientated care using the balanced care model. It summarizes the steps, obstacles and mistakes that have been encountered in the implementation of community mental health care worldwide and presents guidelines on how to avoid them. It proposes realistic and achievable recommendations for the development and implementation of community-orientated mental health care over the next ten years. These guidelines will be of practical use to psychiatrists and other mental health and public health practitioners at all levels worldwide, including policy makers, commissioners, funders, non-governmental organisations, service users and carers. A core message of the book is that the mental health sector will more powerfully advocate for better services in future through strong and unified alliances, especially with powerful representation from consumer/service user and carer groups.

Community-orientated care draws on a wide range of practitioners, providers, care and support systems (both professional and non-professional), though particular components may play a larger or lesser role in different settings depending on the local context and the available resources, especially trained staff. Research by a WPA task force has demonstrated that most of the challenges are common and global, but with local variations. The book is therefore relevant to psychiatrists and mental health workers in developed countries who are trying to deliver better health care on reduced budgets and for those in the developing economies who are in the position to modernise their mental health care. It provides clear, concise guidance on policy and practice decisions, learning from what has and has not worked in regions in the world.

The book contains many tables documenting the evidence, supported by an essential reference list, and a Key Points summary for each chapter.

Highly Commended in the Psychiatry section of the 2012 BMA Book Awards.

SECTION 1

Introduction

CHAPTER 1

Global mental health: the context

Introduction

Mental health problems are common, with over 25% of people worldwide developing one or more mental disorders at some point in their life [1]. They make an important contribution to the global burden of disease, as measured by disability-adjusted life years (DALYs). In 2004, for example, neuropsychiatric disorders accounted for 13.1% of all DALYs worldwide, with unipolar depressive disorder alone contributing 4.3% towards total DALYs. In addition, 2.1% of total deaths worldwide were directly attributed to neuropsychiatric disorders. Suicide contributed a further 1.4% towards total deaths, with 86% of all suicides being committed in low- and middle-income countries (LAMICs) each year [2]. A systematic review of psychological autopsy studies of suicide reported a median prevalence of mental disorder in suicide completers of 91% [3]. Life expectancy is up to 20 years lower in people with mental health problems than in those without, due to their higher levels of physical illnesses and far poorer health care [4]. Mental health problems therefore place a substantial burden on individuals and their families worldwide, in terms of both diminished quality of life and reduced life expectancy. The provision of any (let alone high-quality) mental health care is vital in reducing this burden [5].

It is in this context that the aim of this book is to present guidance on the steps, obstacles and mistakes to be avoided in the implementation of community mental health care, and to make realistic and achievable recommendations for the development and implementation of community-oriented mental health care worldwide over the next 10 years. We intend that this guidance will be of practical use to the whole range of mental health and public health practitioners at all levels, including policy makers, commissioners, funders, nongovernmental organizations (NGOs), service users and carers. Although a global approach has been taken, the focus is mainly upon LAMICs, as this is where challenges are most severe and most pronounced.

What is community-oriented mental health care?

How can we understand and define community-oriented mental health care? Historically speaking, in the more economically developed countries, mental health service provision has been divided into three periods [6]:

1. The rise of the asylum (from around 1880 to 1955), which was defined by the construction of large asylums that were far removed from the populations they served.

2. The decline of the asylum or “deinstitutionalization” (after around 1955), characterized by a rise in community-based mental health services that were closer to the populations they served.

3. The reform of mental health services according to an evidence-based approach, balancing and integrating elements of both community and hospital services [6–8].

One particular approach that can be useful is the “Balanced Care Model”. This is the view that there is no strong evidence that a comprehensive mental health service can be provided with inpatient services alone, nor with community services alone. Rather there needs to be a careful balance of community-based and hospital-based care. The precise mixture of these elements needed will be quite specific to any particular time and place. Nevertheless, the Balanced Care Model is based upon a set of fundamental principles, namely that services should:

• be close to home
• provide interventions for disabilities and for symptoms
• be specific to the individual needs
• reflect the priorities of service users
• include both mobile and static services.

In practice these principles will usually mean that most mental health and related services will need to be provided in settings close to the populations served, with hospital stays being reduced as far as possible (in number and duration), and that over time a progressively greater proportion of the mental health budget is spent upon community rather than hospital services [9].

The resources available in LAMICs are so far below those in high-income countries that the Balanced Care Model is organized in a tiered way to indicate service developments that are feasible and realistic at difference levels of resource. For example, the number of psychiatrists per 100 000 population is 5.5–20.0 in Europe and 0.05 in Africa, while there are 87 beds for the same population in Europe compared with 0.34 in Africa, and the proportion of the total health budget dedicated to mental health is 5–12% in Europe and less than 1% on average in Africa. Therefore, to take each resource level in turn:

1. In low-resource settings, the focus is on establishing and improving the capacity of primary health care facilities to deliver mental health care, with limited specialist back-up. Most mental health assessment and treatment occurs, if at all, in primary health care settings or in relation to traditional/religious healers. For example, in Ethiopia, most care is provided within the family or close community of neighbors and relatives: only 33% of people with persistent major depressive disorder reach either primary health care or traditional healers [10,11].

2. In medium-resource settings, in addition to primary care mental health services, an extra layer of general adult mental health services can be developed. This consists of all of the following five categories: outpatient/ambulatory clinics; community mental health teams; acute inpatient services; community-based residential care; and work, occupation and rehabilitation services (see Appendix A for further descriptions of these services).

3. In high-resource countries, in addition to the services indicated for points 1 and 2, as more resources become available, more specialized services can be provided, in the same five categories. These may include, for instance, specialized outpatient and ambulatory clinics, assertive community treatment teams, intensive case management, early intervention teams, crisis resolution teams, crisis housing, community residential care, acute day hospitals, day hospitals, nonmedical day centers, and recovery/employment/rehabilitation services. It is this Balanced Care Model that is used here as the overall framework in considering community-oriented care. This model is described in more detail in Chapter 10.

In low-resource settings, community-oriented care will be characterized by:

• A focus on population and public health needs.
• Case finding and detection in the community.
• Locally accessible services (i.e. accessible in less than half a day).
• Community participation and decision-making in the planning and provision of mental health care systems.
• Self-help and service-user empowerment for individuals and families.
• Mutual assistance and/or peer support of service users.
• Initial treatment by primary care and/or community staff.
• Stepped care options for referral to specialist staff and/or hospital beds if necessary.
• Back-up supervision and support from specialist mental health services.
• Interfaces with NGOs (for instance in relation to rehabilitation).
• Networks at each level, including between different services, the community, and traditional and/or religious healers.

Community-oriented care, therefore, draws on a wide range of practitioners, providers, care and support systems (both professional and nonprofessional), though particular components may play a greater or lesser role in different settings depending on the local context and the available resources, particularly trained staff.

Fundamental values and human rights

Underpinning the successful implementation of community-oriented mental health care is a set of principles that relate on the one hand to the value of community and on the other to the importance of self-determination and the rights of people with mental illness as persons and citizens [12,13]. Community mental health services emphasize the importance of treating and enabling people to live in the community in a way that maintains their connection with their families, friends, work, and community. In this process it acknowledges and supports the person's goals and strengths to further his/her recovery in his/her own community [14].

A fundamental principle supporting these values is the notion of people having equitable access to services in their own locality in the “least restrictive environment”. While recognizing the fact that some people are significantly impaired by their illness, a community mental health service seeks to foster the service user's self-determination and his/her participation in processes involving decisions related to his/her treatment. Given the importance of families in providing support and key relationships, their participation (with the permission of the service user) in the processes of assessment, treatment planning, and follow-up is also a key value in a community model of service delivery.

Various conventions identify and aim to protect the rights of service users as persons and citizens, including the recently ratified United Nations (UN) Convention on the Rights of Persons with Disability (UNCRPD) [...

Table of contents

• Cover
• Series
• Title Page
• Copyright
• List of Contributors
• Foreword
• Acknowledgements
• Section 1: Introduction
• Section 2: Implementation of community mental health services
• Section 3: Recommendations
• Appendix A: Terminologies
• Appendix B: Questions from a survey conducted with regional experts in the Africa region
• Appendix C: Internet resources
• Index