COMMUNITY PSYCHIATRY

INTRODUCTIONCommunity health service was concerned mainly with the control of communicable diseases. In the course of development, it has become increasingly concerned with every health aspect of life of individuals in the community.Psychiatry, has developed as a personal service to the mentally ill individual, Psychiatrists have attempted to contribute to preventive aspects of mental illness.However, preventive psychiatry remains in its infancy and needs much community efforts to be well developed.CAUSES OF MENTAL ILLNESSThe concept of multiple factors in the causation of psychogenic disorders has become generally accepted.

The factors are considered to involve the individual, the family and the community. OBJECTIVESPromote mental health in the community.Maintain if possible the mentally ill within the community itself.Avoid unnecessary admission and restraint in special hospitals.Provide social therapy.Care and treatment are being delivered close to home,Interventions are being given to improve disabilities treatment and care given are specific to the diagnosis and needsServices reflect the priorities of service userServices are coordinated between mental health professions and other agenciesServices are mobile rather than static e.g. home treatmentsDownsizing the psychiatric InstitutionsReduce referrals to institutionsMainstream Out-patient clinicacute care (inpatient) state/district hosp.Hospital based community careAcute home careAssertive community treatmentFollow-up services for patients with complex needsAll of these services include elements of psycho-education, family-based intervention, work-based intervention and illness self management skills.Custodial Care/Institution (past)Care in Community (present & future)COMMUNITY PSYCHIATRYHOSPITALISATIONAcute stay if needed short as possible (early discharge)

Optimizing treatment

Ensuring continuity of care with other services in the community

ACUTE TREATMENTAssessment with Threshold Assessment Grid (TAG) Function to assesses the severity of a persons mental health problems Camberwell Assessment of Needs-Short Schedule (CANSAS):Function to assess of the needs of people with severe mental health5 dimensions to be considered:Safety, care, diagnosis, disability and duration of distressAcute treatment at home is offered as alternative to hospitalizationEngage family member to assist in patients managementTeam buildingExample TAG

Example of CANSAS

ACUTE TREATMENTDevelop alliance with patient and familyPrevent harm by risk assessment & risk managementControl disturbed behaviorSuppress symptomsConnect family and patients with follow up resourcesPsycho education:What is psychosis? Early signs? Familys role? How to help?Multidisciplinary approachEARLY DISCHARGE PROGRAMPatient may be admitted due to severe risk or due to logistic problems (e.g. during weekends or after office hours)Assessment followed by engagement of family done as soon as possiblePatient is discharged as soon as possible with a care plan, acute treatment or assertive treatment will be provided at homeASSERTIVE COMMUNITY TREATMENT (ACT)Dealing with severe mental illness with complex needs. Serve outpatients whose symptoms of mental illness result in serious functioning difficulties in several major areas of lifeSchizophrenia, mood disorder, organic disorder, withDisabilityUnable to care for self independentlyCannot sustain relationshipsSymptoms current or enduringRecurrent crises and frequent admissionsSignificant risk to self and othersan explicit mission to promote the participants' independence, rehabilitation, and recovery, and in so doing to prevent homelessness, unnecessary hospitalization, and other negative outcomes. Begin in early 1970s due tothe heyday of deinstitutionalization, when large numbers of patients were being discharged from state-operated psychiatric hospitals to an underdeveloped, poorly integrated "nonsystem" of community services characterized by serious "gaps" and "cracks12MAINTENANCEAimshelp with stressprovide supportprevent relapseincrease adaptation to live in communityhelp recovery

Strategiesengagementadherence to medicationcontinue educationimprove coping skillsfamily and social supportworkPLANNING, POLICYClearly states roleof PRIMARY HEALTH CARE in providing mental healthservices NATIONAL MENTAL HEALTH POLICYPrimary care Mental Health PromotionEarly Detection of Mental IIlnessf/u of stable cases & defaulter tracing of these patientsPsychosocial Rehabilitation in Community

Integration of Mental Health Program in the Primary Health Care Empowerment of Family Physician

SERVICES PromotionTreatment &RehabilitationPrevention - primary - secondary

Mental Health FrameworkContinuing CareHealthy Lifestyle Campaign 2000 Public Awareness Empowerment- Training On Coping Skills Change lifestyle - Stress Management - Anger ManagementMental Health PromotionLevels of Care & InterventionSelf and family careInformal and formal community care/supportoutside the health sectorMental health care through primary health care servicesCommunity mental health services(outpatient/outreach)Mental hospitalPsychiatric service at general hospital/clinics123456low low highhighQuantity of services neededCostsFrequency of need5 evidence-based practices in Illness Self Management and Recovery (IMR):Illness managment1. PsychoeducationIs teaching information about mental illness and its treatment, which improves consumers understanding of their disorder and their capacity for informed treatment decision-making. Illness management

In Malaysia, a psychoeducational package is available in 5 training modules covering:Illness management

2. Behavioural tailoringIs helping consumers fit taking medication into daily routines by building in natural reminders (such as putting ones tooth brush by ones medication dispenser), which improve medication adherence and can prevent relapses and rehospitalization.Illness management

3. Relapse prevention trainingTeaching consumers how to recognize situations that trigger relapses and the warning signs of a relapseDeveloping a plan for responding to those signsIllness management

Illness management4. Coping skills trainingImprove consumers ability to cope,Deal with persistent symptoms by helping them identify and practice coping strategiesHence, decrease distress and severity of symptoms.

ModulKemahiranKesihatan Mental

Illness management5. Social skills trainingHelps consumers strengthen their social supports and and bonds with others by practicing interpersonal skills in role plays and real life situations,

resulting in more rewarding relationships and better illness managementA) Supported employment: Individual Placement & Support

Rapid job search (Job search)Attention to patient preferences (Job match)Ongoing support and on going training for the job without a time limit (Job coach)B) Supported educationis the process of helping people with a diagnosis of mental illness return to education.Involve:Target to get into schoolCampus supportFamily interventionFamily interventionFamilies with high Expressed emotions (high levels of criticism, hostility, or over involvement) were associated with more relapses in people with schizophrenia (Brown and Leff,1972).

Family interventionFamily Intervention program: EngagementEnlist family members in active management of patients, Build on the strength available in the familyCommunication TrainingEducationProblem solving

20% have comorbidities, with substance abuse being the commonest (80%).

Functions of support groupsEmotional supportShare experiences and decrease negative emotionsForm friendships and Reestablish networkDecrease isolationEstablish hope and focus on positive rolesInformation provisionHelp increase knowledge on illness and services, demystify illness, enhance coping and problem solvingAdvocacyPotential for power and influenceEducation psychoeducationfocus on patients outcomes& improving family outcomes

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