Community mental health nursing

COMMUNITY MENTAL HEALTH
Sudipta Debnath
Jr. lecturer
CON, CMC

Introduction
• The methods of treating mental illness have
changed dramatically in the past century.
• Community mental health as a treatment
philosophy, was mandated by the Community
Mental Health Centers Act of 1963;
• Thus, bringing about the shift of mental health
care from the institution to the community, and
heralding the era of deinstitutionalization.

Community mental health
development in India
• Phase I:
– Colonial period prior to India’s attaining
independence.
– Establishment of lunatic asylums in different parts of
the country.
• Phase II:
– During 1950s
– Establishment of mental hospitals at Bangalore
(1954), Amritsar (1947), Hyderabad (1953), Srinagar
(1958), Jamnagar (1960) and Delhi (1966).
• Phase III:
– During mid 1960s
– Growth of general hospital psychiatry units.

Contd…
• Phase IV:
– During 1970s
– Extension of care from mental hospitals and
general hospitals to the primary health care
centers and the community.
– Bengaluru and Chandigarh initiated pilot
programs to develop and evaluate an extension
of mental health services for the rural
underprivileged population.
• Phase V:
– During 1990s

Contd…
–Substantial increases in funding and
improvement in the condition of many
mental hospitals.
–Voluntary and NGOs taking an active
interest in various aspects of mental health.
–Growth of private sector in psychiatric
services.
–Growth of private consultant psychiatrists.

General attitude towards of mentally
ill
1. In general the community responds to the mentally ill
through denial, isolation and rejection.
2. There is also a lack of understanding of mental illness
as any other illness, and a tendency to reject both the
patient and those who treat them.
3. Mentally ill are viewed as people with no capacity for
understanding.
4. People feel mental illness cannot be cured, and even if
the patient gets better, complete physical rest is
considered essential.
5. The mentally ill are being perceived as aggressive,
violent and dangerous.

Misconceptions about mental illness
1. Mental illness is caused by supernatural power and it
is the result of a curse or possession by evil spirit.
2. Mentally ill people show bizarre behavior.
3. Mentally ill people are dangerous.
4. Mental illness is something to be ashamed.
5. Mental illness is not curable.
6. Mental illness is contagious.
7. Mental illness is completely hereditary.
8. Marriage can cure mental illness.
9. Mental hospitals are places where only dangerous
mentally ill individuals are treated and restraint is a
major form of treatment.

Community mental health
• Operationally community mental health
means, “the process of involving in raising the
level of mental health among people in a
community and reducing the number of those
suffering from mental disorders”.

Community mental health nursing
• Community mental health-psychiatric nursing
is the application of specialized knowledge to
populations and communities to promote and
maintain mental health, and to rehabilitate
populations at risk that continue to have
residual effects of mental illness.

Goals of community mental health nursing
1. To provide prevention activities to populations for the purpose of
promoting mental health.
2. To provide interventions as early as possible.
3. To provide corrective learning experiences for client-groups who have
deficits and disabilities in the basic competencies needed to cope in
society, and to help individuals develop a sense of self-worth and
independence.
4. To anticipate when populations become at risk for particular emotional
problems and to identify and change social and psychological factors
that diversely affect people's interaction with their environments.
5. To develop innovative approaches to primary prevention activities.
6. To assist in providing mental health education to populations about
mental health and illness and to teach people how to assess their
mental health.

Model of Preventive psychiatry
• Preventive psychiatry is best defined as “ all
activities undertaken in the community in the
name of promotion of mental health and the
prevention of mental illness”.
• The basic model of community mental health
was defined by Gerald Caplan in 1967.

• The predominant characteristics of community
psychiatry are:
1. Responsibility to a population for mental
health care delivery.
2. Treatment close to the patient in community
based centres.
3. Provision of comprehensive services.
4. Multi-disciplinary team approach.
5. Providing continuity of care.
6. Emphasis on prevention as well as treatment.
7. Avoidance of unnecessary hospitalisation.

Levels of prevention
• In the 1960s, psychiatrist Gerald Caplan described
levels of prevention specific to psychiatry.
• He described primary prevention as an effort
directed towards reducing the incidence of mental
disorders in a community.
• Secondary prevention refers to decreasing the
duration of disorder while;
• Tertiary prevention refers to reducing the level of
impairment.

Mental health services
• Primary level:
– Prevention is geared to individuals and to larger
specialized populations
– E.g. early childhood-parent education programs,
infant stimulation programs, early socialization
programs such as play groups attempt to effect
primary prevention of mental disorders.
– Although these programs would be valuable for
most families, they are considered especially
preventive in those families where there are
more apparent risk factors (e.g pregnant
teenagers, homeless families etc.)

• Secondary level:
– It is provided by crisis intervention services,
including hot lines, walk-in-services, brief
psychotherapy and hospitalization when
necessary.
– Consumer education groups and self help
groups also play a role in providing support to
individuals and families during period of
increased stress or exacerbation of symptoms
of mental disorders.
– Psychoactive medications are also therapeutic
measures of secondary prevention.

• Tertiary level:
– Need to be available in the form of family
supports, home services, residential placements
and half way homes.
– Liaison workers, reliable friends, family
members or sponsors are needed to be helped
to negotiate complex systems of care and to
advocate for the client.
– Short term and long term hospitalization may
be necessary for certain clients and should be
available as a part of the mental health service
delivery system.

Nurses role : Primary prevention
• Individual centered intervention
– Antenatal care to the mother and educating her regarding
the adverse effects of irradiation, certain drugs and
prematurity.
– Ensuring timely and efficient obstetrical assistance to
guard against the ill effects of anoxia and injury to the
newborn at birth.
– Dietary corrections to those infants suffering from
metabolic disorders.
– Correction of endocrine disorders.
– Liberalization of laws regarding termination of
pregnancy, when it is unwanted.
– Training programs for physically, and mentally
handicapped children like blind, deaf, mute and mentally
subnormal etc.

Contd…
– Counseling the parents of physically and mentally
handicapped children, with particular reference to the
nature of defects. The parents need to accept the child
and emotionally support the child and be satisfied with
limited goals in the field of achievement.
– Fostering bonding behaviors. Explaining importance of
warm, accepting, intimate relationship and avoiding the
prolonged separation of mother and child are essential.
• Interventions oriented to the child in the school
– Teaching growth and development to parents and
teachers.
– Identifying the problems of scholastic performance and
emotional disturbances among school children and
giving timely intervention. School teachers can be taught
to recognize the beginning symptoms of problems and
referring to appropriate agencies.

• Family centered interventions to ensure harmonious
relationship
– Consulting with parents about appropriate disciplinary
measures.
– Promoting open health communication in families.
– Rendering crisis counseling to the parents of physically
and mentally handicapped children.
– Ensuring harmonious relationship among members of the
family and teaching healthy adaptive techniques at the
time of stress producing events.
• Interventions oriented to keep families intact
– Extending mental health education services at Child
Guidance Clinics about child rearing practices; at parent-
teacher associations regarding the triad relationship
between teacher, child and parent; and at various
extramural health agencies regarding integration of
mental health into general health practice.

– Strengthening social support for the frustrated aged and
helping them to retain their usefulness.
– Promoting educational services in the field of mental
health and mental hygiene.
– Developing parent-teacher associations.
– Rendering home-maker services – when there is absence
of the mother from home due to illness or other reasons for
prolonged periods, the public health nurse can arrange for
the service.
– Providing marital counseling for those having marital
problems.
• Interventions for families in crisis
– In developmental crisis situations such as the child passing
through adolescence, birth of a new baby, retirement or
menopause, death of a wage earner in the family, desertion
by the spouse etc. crisis intervention can be given at
• Mental hygiene clinics
• Psychiatric first-aid centers
• Walk-in clinics

• Mental health education
– Conduct mass health education programs through film
shows, flash cards and appropriate audio-visual aids
regarding prevention of mental illnesses and
promotion of mental health in the community.
– Educate health workers regarding prevention of
mental illness so that they can function effectively in
all the areas of prevention.
• Society-centered preventive measures
– Community development Culturally deprived families
need biological and psychosocial supplies. They need
better hygienic living conditions, proper food,
education, health facilities, and recreational facilities.
Otherwise, psychopath, alcoholism, drug addiction,
crime and mental illness, will result in such situations.
– Collection and evaluation of epidemiological, bio-
statistical data.

Nurses role : Secondary prevention
• Early diagnosis and case finding:
– This can be achieved by educating the public,
community leaders, industrialists, Mahila mandals,
Balwadis etc. in how to recognize early symptoms of
mental illness.
– Case finding through screening and periodic
examination of population at risk, monitoring of
clients etc.
– Thus in clinics, schools, home health care and the
work place, community mental health nurses detect
early signs of increased levels of anxiety, decreased
ability to cope with stress and failure to perceive
self, the environment and/ or reality accurately, and
provide direct services as appropriate.

• Early reference:
– The public should be educated to refer these cases to
proper hospitals as soon as they recognize early
symptoms of mental illness.
• Screening programs :
– Simple questionnaires should be developed to identify
the symptoms of mental illness, and administration of
the same in the community for early identification of
cases.
– These questionnaires can be simplified in local
languages, and used widely in the colleges, schools,
industries etc.
• Early and effective treatment for patient, and if
necessary, to family members as relevant; providing
counseling services to caregivers of mentally ill patients.

• Training of health personnel :
– Orientation courses should be provided to health
workers to detect cases in the course of their routine
work.
• Consultation services :
– Nurses working in general hospitals may come
across various conditions such as puerperal
psychosis, anxiety states, peptic ulcer, ulcerative
colitis, bronchial asthma etc.
– These basic care providers need guidance and
consultation to deal with these conditions in an
effective manner.
• Crisis intervention :
– If crisis is not tackled in time it may lead to suicide
or mental disorders.
– Sometimes anticipating the crisis situation and
guiding the individual in time can help them to cope
with the crisis situation in a better way.

Role of a Nurse in Tertiary Prevention
• Family members should be involved actively in the
treatment program so that effective follow-up can be
ensured.
• Occupational and recreational activities should be
organized in the hospital so that idling is prevented.
• Community based programs can be launched through
meeting with the family members when the need for
discharge from the hospital should be emphasized.
– These programs can be implemented through day
hospitals, night hospitals, after care clinics, half-way
homes, ex-patient hostels, foster care homes etc.
– Follow up care can be handed over to community
health nurses.

• There should be constant communication between the
community health nurses and the mental health institution
regarding the follow up of the discharged patient.
– The ultimate aim of the hospital and community based
programs is to re-socialize and re-motivate the patient for a
functional role in the community, consistent with his
resources.
• There are a wide range of services that need to be provided to
patients as part of the tertiary prevention program.
– Nurses need to be familiar with the agencies in the
community that provide these services.
– Collaborative relationships between mental health care
providers and community agencies are absolutely essential
if rehabilitation is to succeed.
• Nurses in the community are in a key position to monitor
community attitudes and help in fostering a realistic attitude
towards the mentally ill.
• Nurses working with families need to foster healthy attitudes
towards the mentally ill member.

Role of nurses
• Carr et al (1984)have identified the following roles for
nurses working in community mental health services:
• Consultative role:
– This means giving advice to other professionals in the
community about the type and level of nursing care
required for a given client group.
• Clinician role:
– Providing direct nursing care to the patients in the
community.
• Therapeutic role:
– Employing psychotherapeutic and behavioral methods for
management of patients.

• Assessor/researcher role:
– The nurse may assess the care given to the client/ client
group, and may also assess the outcome of ongoing care
programs.
• Educator:
– Creating awareness in the community about mental health
and mental illness with special focus on vulnerable
groups.
• Trainer/Manpower facilitators:
– Training of paraprofessionals, community leaders, school-
teachersand other care-giving professionals in the
community.
• Manager/Administrator:
– Management of resources, planning and coordination.

• Domiciliary care:
– Services are provided to the client by visiting their
homes.
– Services like administration of medications, assessment
of the level of functioning and improvement of patients,
monitoring of side-effects of drugs, counseling of
patients and family members are offered at the client's
home setting.
• Liaison role:
– Nurses working in the community help the clients and
the family members by bridging the gap between the
client and the hospital, client and the employers and also
by networking in the community for resource
development.

Community Facilities For Psychiatric
Patients
• In the community, seven provisions are required to
replace long-term care in hospital:
i. Suitable well-supported carers
ii. Suitable accommodation
iii. Suitable occupation
iv. Arrangements to ensure the patient's
collaboration with treatment.
v. Regular reassessment, including assessment of
physical health
vi. Effective collaboration amongst carers
vii. Continuity of care and rapid response to crises

Some facilities available include:
• Psychiatric hospitals:
– Hospitals have become part of a continuum of mental
health services available to patients and their families,
and offer a variety of treatments for psychiatric
disorders.
• Partial hospitalization:
– Partial hospitalization is an innovative alternative to
hospitalization.
– It is ideally suited to most of the psychiatric syndromes,
particularly chronic psychotic disorders, neurotic
conditions, personality disorders, drug and alcohol
dependence and mental retardation.
– Day care centers, day hospitals and day treatment
programs come under partial hospitalization.

• Advantages of Partial hospitalization:
– lesser separation from families,
– more involvement in the treatment program
– lessening of patient's preoccupation with the
illness, which may be intensified by full
hospitalization.
• E.g. Sanjivini, New Delhi; SCARF, Chennai;
Association of the Friends of Mentally Ill, Mumbai;
Institute of Mental Health, Ahmedabad; Psychiatric
Center, Kolkata; NIMHANS, Bangalore.

• Quarter way homes:
–This is a place usually located within the
hospital campus itself, but not having the
regular services of a hospital.
–There may not be routine nursing staff or
routine rounds, and most of the activities of
the place are taken care of by the patients
themselves.
–Examples of such homes are 13th and 14th
psychiatric wards of NIMHANS at
Bangalore.

• Halfway home:
– A halfway home is a transitory residential center
for mentally ill patients who no longer need the
full services of a hospital, but are not yet ready
for a completely independent living.
– It attempts to maintain a climate of health rather
than of illness, and to develop and strengthen
individual capacities.
– At the same time it enables the recognition of
problems that require medical attention, and
permits the discovery of conditions in the
community which are acting adversely on the
individual.
– Thus, halfway homes have a major role in the
rehabilitation of the mentally ill individual.

• Objectives of Half way homes
– To ensure a smooth transition from the hospital to
the family.
– To integrate the individual into the mainstream of
life.
• Activities
– Community mental health nurses play a vital role
in monitoring the progress of discharged patients
in halfway homes, especially with regard to their
medication regimen and coordination of care.
• E.g. Medico-Pastoral Association, Bangalore;
Atmashakti Vidyalaya, Bangalore; Richmond
Fellowship, Bangalore; Puraskara Aftercare Home,
Bangalore.

• Self-help groups
– Self-help groups are composed of people who are trying to cope
with a specific problem or life crisis, and have improved the
emotional health and well being of many people.
– Usually organized with a particular task in mind, such groups do
not attempt to explore individual psychodynamics in great depth or
to change personality functioning significantly.
– E.g. Alcoholic Anonymous (AA), Association for Mentally
Disabled (AMEND).
• Suicide prevention centres:
– There are many suicide prevention centers in India in the voluntary
sectors doing good work and helping those in need. Some of them
are:
• Helping Hands and MPA in Bangalore;
• Sneha in Chennai [+91(0)4424640050, +91 (0) 44 2464 0060]
• Sahara in Mumbai
• Sanjivini and Sumaitri (Helpline 1: 2338 9090) in New Delhi

National Mental Health Program
• Launched in 1982 in India
• Objectives:
1. To ensure availability and accessibility of minimum
mental health care for all in the foreseeable future,
particularly to the most vulnerable and
underprivileged sections of population.
2. To encourage application of mental health
knowledge in general health care and in social
development.
3. To promote community participation in the mental
health service development and to stimulate efforts
towards self-help in the community.

Aims of NMHP
1. Prevention and treatment of mental and
neurological disorders and their associated
disabilities.
2. Use of mental health technology to improve
general health services.
3. Application of mental health principles in
total national development to improve quality
of life

Approaches of NMHP
1. Integration of mental health care services
with the existing general health services.
2. Utilization of the existing infrastructure of
health services and also deliver the minimum
mental health care services.
3. Provision of appropriate task-oriented
training to the existing health staff.
4. Linkage of mental health services with the
existing community development program.

Strategies of NMHP
1. Integration of mental health with primary
health care through the NMHP.
2. Provision of tertiary care institutions for
treatment of mental disorders.
3. Eradicating stigmatization of mentally ill
patients and protecting their rights through
regulatory institutions like the central mental
health authority and state mental health
authority.

Components of NMHP
1. Treatment: Multiple levels were planned.
• A Village and sub-center level multipurpose workers
(MPW)and health supervisors (HS), under the supervision
of medical officer(MO) to be trained for:
a. management of psychiatric emergencies
b. administration and supervision of maintenance
treatment for chronic psychiatric disorders
c. diagnosis and management of grand-mal epilepsy,
especially in children
d. liaison with local school teachers and parents
regarding mental retardation and behavioral problems
in children
e. counseling in problems related to alcohol and drug
abuse

• MO of Primary Health Centre (PHC)aided by HS, to be
trained for:
a. supervision of MPW's performance
b. elementary diagnosis
c. treatment of functional psychosis
d. treatment of uncomplicated cases of psychiatric
disorders associated with physical diseases
e. management of uncomplicated psychosocial
problems
f. epidemiological surveillance of mental morbidity

• District hospital:
– It was recognized that there should be at least
one psychiatrist attached to every district
hospital as an integral part of the district health
services.
– The district hospital should have 30-
50psychiatric beds.
– The psychiatrist in a district hospital was
envisaged to devote only a part of his time to
clinical care and a greater part in training and
supervision of non-specialist health workers.

• Mental hospitals and teaching psychiatric
units: Major activities of these higher centers
of psychiatric care include:
–help in care of 'difficult' cases
–Teaching
–specialized facilities like, occupational
therapy units, psychotherapy, counseling
and behavioral therapy

2. Rehabilitation
– The components of this sub-program include
treatment of epileptics and psychotics at the
community levels and development of rehabilitation
centers at both the district level and higher referral
centers.
3. Prevention
– The prevention component is to be community
based, with initial focus on prevention and control of
alcohol-related problems.
– Later on, problems like addictions, juvenile
delinquency and acute adjustment problems like
suicidal attempts are to be addressed.

Community mental health nursing

Community mental health nursing

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