Introduction to Community Psychiatry
Psychiatry is the branch of medicine that focuses on mental disorder and their diagnosis, management and prevention (Oxford Medical Dictionary). According to the World Health Organisation mental health problems account for 20% of total disability in the European Region and one in four people at some time in life are affected by mental health problems.
For centuries, mental illnesses were believed to be as having supernatural causes and the way these mentally ill were treated was determined by spiritual and religious beliefs and explanations of the societies (Funk et al, 2003). The explanation of mental illness as physical state rather than being supernatural causes did not come until early the 17th century and people with mental illness and unable to be looked after by themselves and their families were kept in workhouses, public jails and private asylums across the Europe (Mind.org, 2008). However, it was not until the 18th century when the mentally ill patients received any formal treatment. The county asylum act in 1808 gave permissive powers to each county's justices to build mental asylums and general hospitals but this development seemed to be very slow and was not carried out by many counties until The Lunacy Act 1845 required each county to provide an asylum for the care of mentally ill and Britain's major hospitals were built in the next twenty five years or so and Broadmoore being one of them that was opened in 1863 but most of these hospitals were still rather custodial institutes (Mind.org, 2008). By the beginning of the 20th century due to ever increasing number of patients and poor funding mental asylums became overcrowded, had lack of hygiene and poor living conditions. The idea of custody and protection changed into treatment and care of mentally ill patients and this process of shifting the care and support towards more humane approach lead to the discrediting and closure of many asylums and this was often termed as ‘deinstitutionalization' (Fakhourya & Priebea, 2007) (Funk et al, 2003). The main transition towards community care as we know it today occurred in 1950s and 1960s. In 1952, Chlorpromazine was introduced; it was the first effective medicine for schizophrenia and this lead to a significant decline in the number of patients in psychiatric hospitals because they could be easily treated outside the institutions (Cameron & Bloye, 2004). The Mental Health Act 1959 set further restrictions in managing the mentally ill and it reinforced the hospital admissions to be voluntary and treatment to be more community based. Gradually the system shifted more towards care in the community and in 1990 community mental health teams were implemented.(ABC) Today most of the patients with mental illnesses are assessed and managed in community and hospital admissions are only brief when necessary (Cameron & Bloye, 2004).
Every day Health services are faced with patients with mental health disorders ranging from mild depression to sever schizophrenia. In the United Kingdom, the mental health service comprises a variety of organisations and usually the first point of contact is General Practitioners. GPs and family doctors have always been playing a major role in identifying and managing mental health problem and 25% of GP consultations are comprised by mental disorders such as mild to moderate mood and anxiety disorders, dementia or cognitive decline and depression. It is also worth noting that a big proportion of those with mental illnesses do not get detected in primary care and according to National Survey of Psychiatric Morbidity only 28.5% patients with mental disorders attending primary care were receiving treatment. ABC. This may be because most of these patients present their symptoms as physical instead of psychological and also some patients will not want treatment because of the fear of stigma in the society. ABC despite modernism in the mental health care and development into community psychiatry the concept of stigmatisation still exists in the community due to historic bias and prejudice against those with mental illnesses that may prevent the patients from seeking help at the right time and lead to worsened situation (Crisp et al, 2005).
Mental health problems are managed by health promoting activities, psychological therapies and medication (abc of mental health, pg12). An important function of primary care consultations is to assess whether certain patients require to be referred to secondary care such as Community Mental Health Team (CMHT) or outpatient psychiatric clinics. Some of the many reasons for referrals are to provide a specific therapy which is not available at Primary Care, for advice and consultation about ongoing treatment or when conditions have failed to resolve despite treatment efforts(ABC pg 14).
As part of our assessment, I had an opportunity to visit some of the mental health care settings. I visited Scutari clinic at St. Thomas' Hospital which is an outpatient clinic providing services to people living in the North Lambeth and I observed that patients were referred by GPs for a review on medications or patients had come for their mental health progress follow-up. I observed two patients in the consultation and both of them had Bipolar Disorder and had been admitted in the hospital for their mental illness so most of the patients who are referred have moderate to severe form of mental illnesses. I learned that patients can also see psychiatrist at outpatient clinic through attachment CMHT as same psychiatrists form part of the CMHT in North Lambeth.
During my visits to North Lambeth CMHT I had a chance to closely observe how CMHT works. CMHT consists of a multidisciplinary team of psychiatrists, psychologists, social workers, community psychiatric nurses, care coordinators and occupational therapists. It is a joint system of health and social services to provide comprehensive care to working age adults within an attachment area and most of the special psychiatric care in the community is coordinated by these services. Most of the patients referred to CMHTs are from attachment General Practice and housing officers amongst other social services who are concerned about those in their attachment and occasionally from hospital specialists. In one of the consultations that I observed the patient had made a direct contact with the CMHT because he was having impulsive thoughts of killing himself and others and did not want to share this with his GP due to embarrassment as he had known the GP since a long time and his whole family was registered with that GP. So patients can contact their local mental health services directly also but the response of CMHTs for requests must be under the Mental Health Act and they must contact other health professionals such as their GP involved in their care.(ABC).
The team is composed of several sub teams such as Duty and Assessment, and Support and Recovery. Everyone who is referred to the community mental health team is assessed by Assessment & treatment team on multi-disciplinary basis and including detailed risk assessment. After that the patient gets offered a range of treatment which can be group or individual based such as Cognitive Behaviour Therapy (CBT). Then the case is presented to the whole team and a care coordinator, who is often a nurse or a social worker, is appointed to each patient. Recovery & support team makes sure that patients get support and advice and deal with issues that are troubling the patients. CMHTs provide services to two groups of people, those who have time limited disorders and after a few weeks or months get referred back to the GP as in one of the consultations I observed that the psychiatrist made the decision to discharge the patient back to the GP as she was now seemed to have made sufficient recovery in her mental state and the psychiatrist reassured her that if she needs further help and support she can ask her GP to refer her back to them; and only a small proportion of patients who need ongoing treatment, care and monitoring for periods of several years because of the nature of their mental disorder remains with the team (Department of Health, 2002). So in the community mental health services health professionals must work flexibly with other professionals to provide both the specific mental health treatment and ordinary human needs to normalise the patients' life in the community.
While many mentally ill patients are provided with specialist mental health care and treatment in the community, some patients who have severe mental health problems require a hospital admission for assessment and treatment. Most of these patients will be admitted on voluntary basis but a few may need to be compulsory detained under a section of Mental Health Act. An application for assessment and treatment of these patients is made an approved social worker with recommendation of two doctors, one of whom must be a psychiatric and another doctor who knows the patient well for second opinion (Department of Health, 2009). As at North Lambeth CMHT a social worker was reviewing a patient's case that had been ignoring all the phone calls and letters sent to him and was also not found by Home Treatment Team and he was not mentally well enough to be left unsupported in the community so the social worker decided that detaining the patient will be best course of action for that patient therefore she was going to arrange with the psychiatric to review the case together and then send an application for detention of the patient in a secure place.
Also, there is a small proportion of patients who, because of their insanity, have committed criminal offences and are too dangerous to be treated in the community or a general hospital ward and require to be detained within secure in-patient setting to enable treatment and support to be provided safely. These patients are kept in Secure Units, high, medium or low depending on the severity of the mental health and behavioural requirement of the patients. Most of the patients admitted to these secure units are referred through criminal justice system and usually detained under the Mental Health Act (1983) Part 3 or the Criminal Justice Act (Department of Health, 2009).
I had an opportunity to visit River House a medium secure unit at Bethlam Royal Hospital; it is built in the shape of air locked doorways, high fences and double jointed hinges on internal doors. The network of these units bridges the gap between high security in-patient services and low security in-patient services to match the needs of those who require to be treated in a more secure environment than a low security or general hospital but do not require a very high level of security (Kirby & McGuire, 1997). It is a central point of providing comprehensive forensic psychiatry services to the patients in the attachment area (Kirby & McGuire, 1997). It is also run by a multidisciplinary team and as well as providing drugs and therapeutic treatments they also prepare the patients to cope in the community after discharge by making sure they are equipped with the practical skills and the experiences. I had a chance to sit in a meeting where they were reviewing some patients' cases. The patients in this setting were much different than the ones I saw in the community in terms of their behaviour, health and mental state. Most of the patients had a history of serious mental illness such as schizophrenia and had been assessed as a risk or potential risks to others. It is very important to achieve the patient's positive attitude towards their treatment by involving them in planning, implementation and evaluation of the treatment as lack of patients' insight into their condition and treatment may prejudice their active and willing acceptance, especially for forensic patients as they are detained for indefinite date of discharge (Kirby & McGuire, 1997). While some of the patients that I observed in the meeting understood their treatment programme and seemed to be cooperating with it to achieve their goals, but there were some who had become very impatient and believed as if it was unfairness for them to be there and hence had excluded themselves from voluntary therapy sessions. I feel it is indeed very hard as a patient to cope with this situation when they are away from their family and loved ones and detained against their wish and they do not have the capacity to understand why this is happening to them. As there was one patient who had not seen his children for seven years and was pleading in the meeting to let him go on a leave to see them but because he was not well enough to manage in the community he could not be allowed on a leave. I felt very sorry for that particular patient but I also knew that this was for his own best interest.
Overall my experience has been very insightful and gave me the opportunity to learn about community mental health in the UK. The institution based mental health system, which would cause dependency, helplessness, hopelessness, and other maladaptive behaviors, has been transformed into community based mental care. Patients referred to psychiatrists are most likely to be managed by community mental health services and if admitted to the hospital in an acute psychiatric ward, patients get discharged after a few days and receive appropriate follow up and support by the community services and this indeed have a better impact on mentally ill as they are kept close and involved with their families and community to help them recover better. However, some patients who are risk to themselves and others require to be detained and treated in the secure units in the hospitals and get prepared to be able to manage in the community. However, fear of stigmatisation and lack of understanding of the importance of mental health care is still a big hurdle in seeking help at the right time. Some of the ways to eradicate this, may be to make sure that mental health is appropriately addressed to children at school and have public awareness campaigns to depict that seeking help from mental health services is exhibiting responsible and appropriate health care behaviour.