The document outlines community care and service provision in psychiatry, emphasizing the evolution of mental health services from asylums to community-based care. It details various models and historical developments, critiques the community psychiatry approach, and highlights the importance of integrating mental health services into primary care. Challenges, successes, and recommendations for improving mental health care delivery, particularly in Nigeria, are also discussed.

1. Community Care
and
Service Provision
in Psychiatry
Dr Timothy O. Adebowale
FWACP
Neuropsychiatric Hospital Aro

2. Lecture Outline
• Concepts and definitions
• Historical developments
• Service components
• Implementation across countries
• Primary care vs. Community Care
• mhGAP & its Implementations.
• Aro Community & Primary Care MH Services
• Telepsychiatry
• Framework for Working with Indigenous MH Systems

3. What is Community Psychiatry
• Community psychiatry is “the branch of psychiatry concerned
with the development of an adequate and coordinated
programme of mental health care for residents of specified
catchment areas”.
• Community care refers to provision of comprehensive mental
health services for a well-defined catchment area,
demarcated geographically and administratively, such as a
borough, district or county. (Farooq and Minhas 2001).
• The principles of community psychiatry, as proposed by
Caplan and Caplan (1967), include:
– responsibility to a population, usually a catchment area defined
geographically
– treatments close to the patient's home
– multi-disciplinary team approach
– continuity of care
– consumer participation
– comprehensive services.

4. Community Mental Health Care (Thornicroft)
• Thornicroft provided a comprehensive definition of
community mental health care as that which comprises the
principles and practices needed to promote mental health
for a local population by:
– Addressing population needs in ways that are accessible and
acceptable
– Building on the goals and strengths of the people who experience
mental illnesses.
– Promoting a wide network of support services and resources of
adequate capacity.
– Emphasizing services that are both evidence based and recovery
oriented.

5. Community care/services
• A whole system of care in which the patient's
community, not a specific facility such as a
hospital, is the provider of care for people
with a mental illness.
• Services that support or treat people with
mental disorders in a domiciliary and
community settings, instead of a psychiatric
hospital or institutions.

6. Models of Community Care
• Conceptual models:
– Hive system
• The hospital as centre of activities with various facilities
such as day hospitals, clinics in the community.
– Advantage of easier administrative system and good range of
professional expertise and beds.
– Disadvantage of poor accessibility for many patients, delay
referral, poor knowledge of community structure, &
concentration of resources in the hospital.
– Network system
• Comprises a network of community resources of which
the hospital is only one of them. The core of the service
is a community-based multidisciplinary team.

7. Dimensions of Community Service/ Care

8. History of modern mental health services
• The recent history of mental health services
can be seen in terms of three periods:
1. the rise of the asylum and mental hospitals
2. the decline of the asylum
3. balancing (fine-tuning) mental health services
(Thornicroft and Tansela 1999).

9. The rise of the asylum (1880-1950)
• Asylums built
– Remotely located,
– Mainly custodial containment
– Basic necessities for survival,
– Wide range of clinical disorders and social abnormalities.
• Staff consists of doctors and nurses only.
• Primacy of containment over treatment.
• Reduced role for the family
• Public investment in institutions

10. The problems of the asylum
• The asylum model produced very poor standards of treatment
and care (Leff 1997)
– institutions and their staff are geographically and professionally
isolated;
– Inadequate quality assurance procedures.
– deficiency of staff training;
– failures of management, leadership, and ineffective administration;
– inadequate financial resources;
– poor reporting and accounting procedures;
– Incidences of maltreatment of patients;
• Evidence of `institutionalism', which is the development of
disabilities as a consequence of social isolation and
institutional care in remote asylums.

11. The fall of the asylum (1950-
• Post world-wars socio-political changes.
• Emergence of effective physical (1940s), pharmacological (1950s) and
psychological therapies.
• Evolving clinical disciplines: psychology, OT, social works.
• Increasing recognised role of the family.
• De-institutionalisation movement with three essential components: (Reid
et al 2001)
– a) the prevention of inappropriate hospital admissions through the provision
of community facilities;
– b) the discharge of long-term institutional patients who have received
adequate preparation
– c) the establishment and maintenance of community support systems for
non-institutionalised patients.
• Focus on pharmacological control and social rehabilitation,
• The works of Erwin Goffman (1968) and Wing and Brown (1970) on
institutionalization of psychiatric patients and the poor standards of care
and quality of life fuelled a political and social movement to close down
the Victorian asylums begining from the in the late 80s.

12. Criticisms of community psychiatry
• De-institutionalisation of those suffering from severe
mental illness in America as a failed social
experiment of the 20th century (Torrey, 1995)
• Fear of trans-institutionalisation (the virtual asylum),
NIMBY..
• Public protection issues, with increasingly restricted
measures such as the care programme approach,
supervised discharge, etc.
– Events in the 1990s turned societal attention from
charitable concern for this group's welfare to an increasing
fear of them.
• Community psychiatric principles can not be
universally applied in different countries (Goldberg,
1987,1992).
– Economic (costs) & Socio-cultural factors
(tolerance/indifference)

13. The era of balanced mental services (1990s-)
• Traditional hospitals being replaced by smaller facilities: DGH,
clinics
• Decrease in the number of beds slows down.
• Importance of families increasingly recognised:
– care giver, therapeutic potential, the burden of care.
• Increasing private investment in treatment and care and focus
in public sector on cost-effectiveness and cost containment.
• More community-based staff and emphasis on
multidisciplinary team working
• Emergence of ‘evidence-based' psychiatry in relation to
pharmacological, social and psychological treatments
• Emergence of concern about balance between control of
patients and their independence …
– The mental capacity act 2005

14. The aims of balanced care
(Thornicroft and Tansela 2002, 2008)
1. Reflect the priorities of service users and
carers;
2. Meet both hospital and community
services needs;
3. Services provided close to peoples’ home;
4. Provision for mobile services.
5. Interventions address both symptoms and
disabilities (Care and Rehabilitation)
6. Treatment specific to individual needs.

15. Components of Modern MHS
(Thonicroft & Tansela, 2004)
• Primary care and general hospital consultation,
outpatient, day hospitals and mobile
community services including home visits.
• Day centre services (Recreational, vocational or
educational, professional/peer support)
• Acute inpatients services/equivalents
• Community based residential services
• Patients and carers participation in every
aspect of care.
• Seamless service interface (e.g. health, social,
judiciary and non-governmental agencies)

16. Low level of resources
Primary care with specialist back-up (Step A)
• Screening and assessment by primary care staff
– Structured assessment & treatment guidelines
• Talking treatments, including counselling and advice
• Pharmacological treatment
• Liaison and training with mental health specialist
staff, when available
– Limited specialist back-up available for:
• training
• consultation for complex cases
• In-patient assessment and treatment for cases that
cannot be managed in primary care - (in ‘general
hospital ward beds’)

17. Medium level of resources
Mainstream mental health care (Step B)
• Out-patient/ shifted out-pt & ambulatory clinics
• Community mental health teams (Drs, Nurses,
Social workers, OT, Psychologists)
• Acute in-patient care
– Psychiatric hospitals
– Psychiatric depts (Gen. Hospitals/ FMCs/THs)
• Long-term community-based residential care
– Hostels/Care homes
• Employment and occupation
– O.T services
– Supportive services

18. High level of resources
Specialised/differentiated mental health services (Step C)
• Specialised clinics for specific disorders or patient groups, including:
– eating disorders, dual diagnosis, treatment-resistant affective disorders,
adolescent services
• Specialised community mental health teams.
– early intervention teams, assertive community treatment
• Alternatives to acute hospital admission.
– home treatment/crisis resolution teams; crisis/respite houses; acute day hospital
• Alternative types of long-stay community residential care.
– intensive 24 h staffed residential provision;
– less intensively staffed accommodation; group homes
– independent accommodation;
• Alternative forms of occupation and vocational rehabilitation:
– sheltered works; supervised/supported work placements;
– cooperative work schemes
– self-help and user groups; club house
– transitional employment programmes

19. History of Psychiatry in Nigeria
• The traditional phase (Pre colonial)
• The transitional phase (1903 – 1954)
• Calabar asylum - 1903
• Yaba asylum - 1907
• Lantoro asylum – 1944
– Colonial physician & Nurses.
• The therapeutic phase (1954 to date)
• Psychiatric Hospitals
• Psychiatric depts. in Teaching Hospitals
• General Hospitals and Federal Medical Centres; Private
services
• Community Psychiatric Services** (Are the criteria met???).
• Integration into PHC

20. THE ‘ARO VILLAGE’ System
• Dr. Lambo introduced the innovatory village system of management of
psychiatric patients in 1956.
• The idea was said to have occurred to him as he took a walk in the
woods of Aro: with the wards still uncompleted, on how patients could
be treated in the community.
• Through negotiations, patients were admitted to nearby villages with
their accompanying relatives, and daytime nursing care were provided
by nurses in these rented apartments for the duration of their
treatment.
• Borrofka and Olatawura (1977) reported that, over a period of 50
months, 512 psychiatric patients were treated in the Aro Village
therapeutic community.
• The majority of those admitted (94.1%) had symptoms of psychosis, with
57.8% discharged by the end of 3 months, and 88.9% by the end of five
months. Of these, 70.3% were judged fit to return to their work.
• The relatives of patients as well as the villagers were involved in the
treatment programme.
• The authors discussed the advantages of the village system of care, as
well as the implications for the future in view of the loosening of
traditional family ties resulting from rapid urbanization in the country.

21. National mental health policy emphasis!
(1991 & 2013)
• Social justice and equity.
• Rights to treatment and support as those
with physical illness and shall be treated
in health facilities as close as possible to
their own community.
• No discrimination on account of mental
illness.
• Mental health services shall as far as
possible be Integrated with general
health services at all levels.

22. • The bulk of psychiatric service provided by the 8
regional psychiatric hospitals and the departments of
psychiatry in 12 medical schools.
• A number of private hospitals, general hospitals and
federal medical centres now provide psychiatric
services.
• Community Mental Health service/programmes of
state governments and NGOs.
• These services are not well coordinated, and mainly
institution based and with service utilisation by
community samples of people with disorders less than
10% (Gureje 2006).
• Despite these facilities, mental health care remains
inadequate, with the ratio of psychiatric beds being
about 0.4 to 10 000 persons (WHO 2001).
Mental Health Service in Nigeria - Summary

23. Treatment Gap in Mental Health
Majority of those who need mental health care
globally, do not receive any treatment.
Treatment gap is highest in LAMI countries (WHO
World Mental Health Surveys)
Developed = 35.5 - 50.3%
Developing= 76.3 – 85.4%
LAMI countries have very low levels of personnel
and resources, e.g. 1psychiatrist:1 million.
Within Nigeria (and other countries), resources are
also unevenly spread (urban/rural; north/south).

24. Community Services in Developing Countries:
Community psychiatry or primary care psychiatry?
• Customised models in developing countries (e.g. India and Pakistan) have
been found quite effective in providing services for large populations
(Goldberg, 1987, 1992)
– Essentially an incorporation of MHS into primary care.
– The objective is to provide mental health care facilities to grossly underserved
populations in rural areas:-
• creating awareness in the community about mental health,
• training primary health care workers in recognition and early management of
common psychiatric disorders
• integration of mental health services with other disciplines in primary care.
– These services target high priority conditions like epilepsy, psychoses, neuroses
and drug-induced problems by various cadres of general health workers.
– Back-up services by trained psychiatrists.
– This model of community psychiatry may be the only viable option for a large
number of developing countries.
• The main objective is to provide minimum essential services to a large
population with the help of allied health professionals working in other
disciplines. Statutory responsibility to a catchment area, continuity of care
may not be possible.
• This can best be seen as primary care psychiatry, and not community
psychiatry. To reduce treatment gap!

25. WHO MHGAP

26. Intervention
• Recommendations to strengthen mental health systems
around the world have been first mentioned in the WHO's
World Health Report 2001,which focused on mental health:
– Provide treatment in primary care
– Make psychotropic drugs available
– Give care in the community
– Educate the public
– Involve communities, families and consumers
– Establish national policies, programs and legislation
– Develop human resources
– Link with other sectors
– Monitor community mental health
– Support more research

27. WHO’s Comprehensive Mental Health Action
Plan 2013-2020
• Strengthen effective leadership and
governance for mental health.
• Provide comprehensive integrated and
responsive mental health and social care
services in community-based settings.
• Implement strategies for promotion and
prevention in mental health.
• Strengthen information systems, evidence and
research for mental health.

28. Rationale and recommendations for mental
health integration (WHO)
Reasons
• The burden
• Comorbidity
• The treatment gap
• Promotes Access
• Reduces Stigma and human
Rights abuse
• Clinical Outcome
• Community Integration
• Manpower development
Recommendations
• Preliminary situational analysis
• Build on existing networks / structures &
human resources
• Funding
• Clear delineation of mental disorders
• Human resource training & competencies
• Recruitment/education of new phc staff
• Availability of medicines
• Supervision and support of primary health
care staff
• Effective referral system & coordination of
a collaborative network
• Intersectoral approach and links with
community services both formal and
informal
• Recording systems for evaluation and
monitoring

29. Aro Community Mental Health Service (2006 -)
Service Components
• Community Outreach Services.
– Mental Health Education and information service (Radio, TV, halls, markets,
schools etc)
– Community (shifted) Out-patient clinics & liaison consultation service
– Community (Home) assessment, treatment and follow-up services.
• Community Residential Rehabilitation Services
– Establishment of a transitional community supported accomodation for
discharged patients.
– Community residential placements and support.
• Community Partnership/liaison Services
– Treatment/Rehabilitation sponsorship and support.
– Supported Vocational training and work placements e.g. barbing, hair
dressing, shoe making, vulcanising, shop assistants, trading etc
– Rehabilitative sheltered Works placements in the hospital (outsourced
cleaning services)
• Community Mental Health Day-Centre Services
– Centre for daytime support, recreational and therapeutic activities
– Treatment services
– Support service for relatives of patients with psychiatric disorders.

30. Aro Primary Care Mental Health
Programme for Ogun State
• Pilot in Abeokuta North Local Govt Area (Feb. 2010)
– 5 priority conditions addressed. (
• State wide Extension (Oct. 2011)
– 20 LGAs
– 40 PHC centres
– 80 Trained Health Workers (Nurses and CHEWs)
– 8 Zonal field supervisors (Community Psychiatric Nurses)
– 4 Zonal field consultant psychiatrists
• School Health Services -2015, 2019 (Ogun State Secondary schools, FCE,
FUNAAB)
• Fortnightly visits for support & supervision – medication supply/referrals mx.
• Monthly programme monitoring meeting.
Web. Link
http://mhinnovation.net/innovations/aro-primary-care-mental-health-programme

31. Challenges to effective integration
Thonicroft et al 2008)
• a) dealing with anxiety and uncertainty;
• b) compensating for a possible lack of structure in community
services;
• c) learning how to initiate new developments;
• d) managing opposition to change within the mental health
system;
• e) responding to opposition from neighbours;
• f) negotiating financial obstacles;
• g) avoiding system rigidities;
• h) bridging boundaries and barriers;
• i) maintaining staff morale; and
• j) creating locally relevant services rather than seeking “the
right answer” from elsewhere.

32. Lessons from Aro Primary Care MH Programme
(– critical success factors)
• Institutional leadership vision and commitment to mental health service
provision at PHC is required.
• Obtaining political will and support from local and state government is
vital to the success of the programme
• Negotiate and engage constructively to remove institutional barriers that
may arise between federal/state/local government or other overlapping
jurisdictions, & skill for leadership across boundaries.
• Creating and sustaining professional commitment among participating
mental health professionals and primary care health professionals.
• An intensive and well-established framework for support and supervision
is necessary to drive and sustain mental health service in PHC.
• There is need to address attrition of trained health workers and also the
sustainability of their skills through training and retraining
• Effective monitoring and evaluation is needed for programme
sustainability.

33. Thank You