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Different models of psychiatric services

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  • 1. DIFFERENT MODELS OF PSYCHIATRIC SERVICES DR SRIJONY AHMED MD PHASE A PSYCHIATRY BSMMU
  • 2. • Historical overview • Different models • Present situation in different countries • Newly evolving systems • Mental health services in Bangladesh
  • 3. Psychiatric service Approved program designed to assist prevention , recovery and management of mental disorders
  • 4. History of Evolution • The religious priory of St Mary of Bethlem, in London used for lunatics from 1377 • Spain has been described as the cradle of humane psychiatry because of the treatment at asylums. • Valencia, opened at the beginning of the century, is said to have removed chains and used games, occupation, entertainment, diet and hygiene as early as 1409
  • 5. • In England the earliest records of private madhouses on a regular basis are from 1670 onwards. • From the beginning, madhouses were automatically subject to the common law of England. One could apply to the courts for redress against wrongful imprisonment in a madhouse as anywhere else. When inspection of madhouses was introduced (in 1774), it was mainly to assist the courts.
  • 6. • Ackernecht argues that psychiatry "reached the status of an independent science" in the eighteenth century. But not due to "developments in medicine but to the philosophy of enlightenment which pervaded the whole century". • Reasons were: Belief in "possession by evil spirits" came to be regarded as "superstition". • Reason was the highest good for the philosophers, so they sympathised especially with those who lost their reason.
  • 7. • The "legge sui pazzi" (law on the insane) established in the Italian Kingdom of Tuscany banned the use of chains and physical punishment in 1774 • In England ,the Vagrancy Act of 1744 : first legal distinction between paupers and lunatics • The 1844 Report recorded public and private asylums employing the non-restraint system and others that used mechanical restraint, but were not using any at the time of their visit. • Philippe Pinel introduced changes to mke thecare more humane in Paris in 1793
  • 8. • The 1808 County Asylums Act was the first Act permitting counties to levy a rate to build asylums • The Lunacy Commission was also to monitor the regulation of county asylums and county licensed houses by JPs, and to regulate the conduct of hospitals for the insane. With the JPs it monitored the admission and discharge of patients from all types of asylum. It collected, collated and analysed data on the treatment of lunacy and advised on the development of lunacy law and policy. It also continued to license London's madhouses.
  • 9. • The 1930 Mental Treatment Act modernised, without replacing, the Lunacy Laws. It reorganized the Board of Control, made provision for voluntary treatment and psychiatric outpatient clinics and modernized the terms used and establish0ent of facilities for aftercare • First International Congress of Mental Hygiene held in Washington. An estimated 4000 people (psychiatrists, psychologists, health planners and others) attended
  • 10. • The 1946 National Health Service Act defined a hospital as an institution for "the reception and treatment of persons suffering from illness or mental defectiveness" (section 79)
  • 11. So upto this Psychiatric hospitals Psychiatric out patient service After care
  • 12. Community Care • In USA Goffman in 1961 showed detrimental effects of total institutionaliation & how it generates chronicity • In UK Wing and Brown in 1970 demonstrated how large mental hospitals characterized by ‘social poverty’ led to ‘clinical proverty’
  • 13. Community Care contd Social rehabilitation Occupational Industrial therapies Day units away from the hospital Hostels for sheltered accomodation
  • 14. • A comprehensive system of community care replaced mental hospitals in Italy • Also psychiatric care came under general hospital • 1959 Mental Health Act in the UK provided a framework for comprehensive & continuing care provision
  • 15. The closure of state psychiatric hospitals in the United States was codified by the Community Mental Health Centers Act of 1963, and strict standards were passed so that only individuals “ who posed an imminent danger to themselves or someone else” could be committed to state psychiatric hospitals This act also established Community Mental Health Centres staffed from several disciplines
  • 16. Community Services ▫ Inpatient care ▫ Outpatient care ▫ Partial hospitalization ▫ Emergency services ▫ Community consultation ▫ Education of the people to a defined catchment area of 75,000 to 2,00000 people
  • 17. In 1977, the National Institute of Mental Health (NIMH) initiated its Community Support Program with the goal to shift the focus from psychiatric institutions and the services they offer to networks of support for individual clients. Ten elements of a community support system : • Responsible team • Residential care • Emergency care • Medicare care • Halfway house • Supervised (supported) apartments • Outpatient therapy • Vocational training and opportunities • Social and recreational opportunities • Family and network attention
  • 18. Ten elements of a community support system : • Responsible team • Residential care • Emergency care • Medicare care • Halfway house • Supervised (supported) apartments • Outpatient therapy • Vocational training and opportunities • Social and recreational opportunities • Family and network attention
  • 19. Another Psychiatric service • Telepsychiatry, also known as e-psychiatry, is the application of telemedicine to the specialty field of psychiatry. • Can allow fewer doctors to serve more patients by improving utilization of the psychiatrist's time. Also make it easier for psychiatrists to treat patients in rural or under-served areas by eliminating the need for either party to travel.
  • 20. Mental Health Services in England Specialist mental health Trust Community mental health teams Crisis resolution teams Provide inpatient care, community and rehabilitation services, residential care centres, day clinics, and drop- in centres. Provide the day-to-day support that is needed to allow a person to remain living in the community. 24 hour service, with provision to referral to emergency or service. Treat a person in the least restrictive environment possible Also responsible for planning after-care once the crisis has passed in order to prevent a further crisis occurring
  • 21. Assertive outreach teams Early intervention in psychosis teams Forensic mental health services Help people who have had a previous history of serious mental health problems, but are no longer in regular contact with mental health services Designed to work with people who are between 18-35 years of age, and who have experienced their first episode of psychosis Treat any mental health problems that may have contributed to a pattern of criminal behaviour and, whenever possible, release a person back into the community after they have completed their sentence, if it is thought safe to do so.
  • 22. Services for children and young people Organised in a four tier system. • Tier 1 - provides treatment for less severe mental health conditions, such as mild depression, an assessment service for children and young people who would benefit from referral to more specialist services. Services at this level are provided by mental health professionals, GPs,health visitors, school nurses, teachers, social workers, youth justice workers, and voluntary agencies. • Tier 2 - provides assessment and interventions for children and young people with more severe or complex health care needs, such as severe depression. Services at this level are provided by community mental health nurses, psychologists, and counsellors.
  • 23. Services for children and young people • Tier 3 - provides services for children and young people with severe, complex and persistent mental health conditions, such as obsessive compulsive disorder (OCD), bipolar disorder, and schizophrenia. Services at this level are provided by a team of different professionals working together (a multidisciplinary team), such as a psychiatrist, social worker, educational psychologist, and occupational therapist. • Tier 4 - provides specialist services for children and young people with the most serious problems, such as violent behaviour, a serious and life-threatening eating disorder, or a history of physical and/or sexual abuse. Tier four services are usually provided in specialist units, which can either be day units or in-patient units
  • 24. Present state • Currently 28% of countries do not have any community based mental health services. • Only 33% of low-income European countries have community based mental health services. • 91% of high income countries have such services.
  • 25. Psychiatric service in Bangladesh Being a low income group country and limited resource for mental health care provision faces a great problem with a high prevalence rate ‘Integration of Mental Health into Primary Care’ has been accepted as an operational plan of the Director General of Health Services (DGHS) WHO-Strongly recommended the delivery of mental service through primary health care system, as a policy for developing countries.
  • 26. Presents scenario Prevalence - 16.05% (Nationwide survey,2003 - 2005) Male - 12.89% Female - 18.99% Epilepsy - 0.09% Mental retardation - 85% to 15.13% Acceptance - 71.4% to 60.50% Care - 63.54% to 15.13%
  • 27. OPD & IPD facilities Government : No. OPD IPD Bed Mental Hospital 1 + + 500 NIMH, Dhaka 1 + + 200 Medical College 13 + + 260 District Hospital 1 + + 05 Armed Forces Medical (CMH) 9 + + 124 Total 25 25 25 1089
  • 28. OPD & IPD facilities Non-government : No. OPD IPD Bed Medical University 1 1 1 24 Private Medical Colleges 35 35 2 50 Psychiatric Clinics 3 2 3 150 Total 39 38 6 224
  • 29. OPD & IPD facilities Total OPD = 25 (govt.) + 25 (non- govt.) = 50 Total IPD = 25 (govt.) + 6 (non- govt.) = 31 Total bed in IPD including mental hospital = 1,089 (govt.) + 224 (non-govt.) = 1,313 Bed : Population = 1 : 1,07,000 (approx.)
  • 30. Existing Govt. Health Delivery System MOH&FW DGHS Medical College Hospital (17) 100 bedded district hospitals 31 bedded Thana Health Complex (464) Community Clinics (18000) Union Health Centre (0 bed) Source : DGHS, GOB
  • 31. No. of upazilla No. of bed 507 31 No. of union health center No. of bed 4484 No bed Current general & mental health services in community
  • 32. Present manpower (trained) Manpower No. Psychiatrists ~120 Civil surgeon 25 Primary health care physician 3500 Health workers 5500 Imam 172
  • 33. Community awareness development programme in 4 model upazila Training provided - Doctors Nurses Health workers Community awareness seminars - 28 Total people participated - 2800
  • 34. Resources & Deficits : Mental Health in Primary Health Care •Psychotropic drugs in PHC centres - Very few •Training hours for medical students - 60 hrs. (4% of total hrs.) •Training hours in nursing school - 135 hrs. (2% of total hrs.) •Training hours for medical assistants & medical technologists - 0 hrs. •Management manuals for PHC staffs - Present •Interactive meeting with alternative / traditional practitioners - Very few Source : WHO-AIMS in Bangladesh, Dhaka
  • 35. Resources & Deficits : Cost of Essential Psychotropic Medicines •Population with free access to psychotropic medicine : < 1% (in government facilities) •Cost of 1 day cheapest antipsychotic : Tk. 5 (4% of daily wage) •Cost of 1 day cheapest antidepressant : Tk. 3 (3% of daily wage)
  • 36. Resources & Deficits: Awareness, Acceptance & Care of Pts. •Awareness on mental health - 85% to 15.13% • Acceptance of mental pts. - 71.42% to 60.50% • Willingness to care of mental pts. - 63.54% to 15.13%
  • 37. Plan of action for integration with PHC within 2016 Scaling up of mental health services in the PHC in the next 5 years sector plan of Government of People’s Republic of Bangladesh (Health Population and Nutrition Sector Development Programme - HPNSDP) NCD, PHC & I S T departments of DGHS have already been doing lot of works specially training programme for PHC workers
  • 38. Support to PHC by enhancing existing referral system Trained PHC Physicians Psychiatrist in district Hospitals ?? Psychiatry Dept. In Nearby Medical Colleges •  NIMH, Dhaka •BSMMU Dhaka  Mental Hospital, Pabna Trained health workers & community clinic workers at PHC
  • 39. Aims of Mental Health Services in the Primary Health care setup. • Prevention and Treatment of Mental and Neurological Disorders and their associated disabilities. • Use of Mental Health Technology to improve general health services. • Application of mental health principles in total National development to improve quality of life.
  • 40. Components of mental health care services • Treatment • Rehabilitation • Prevention
  • 41. THE WORLD HEALTH REPORT MAKES 10 RECOMMENOATIONS FOR ACTION • Provide treatment in primary care • Make psychotropic drugs available • Give care in the community • Educate the people • Involve communities, families & consumers. • Establish national policies, programs and legislation. • Develop human Resources • Link with other sectors • Monitor community mental health • Support more research.