community mental health

Community mental health
Chetraj Pandit BPH,MPH
Lecture, YCHS, Kathmandu,
Nepal
2/16/2020 1Chetraj Pandit

Mental health in community
• Community services include:
• Psychiatric wards of general hospitals,
• local primary care medical services,
• day centers or,
• community mental health club houses centers, and
• self-help groups for mental health.
• The services may be provided by government organizations and
mental health professionals, including specialized teams providing
services across a geographical area, and may be provided by private
or charitable organizations.

• A community mental health program should :
• Provide mental health care in the community itself
• Focus services on the total community
• Focus on the preventive and promote services
• Provide continuing and comprehensiveness of services
• Provide indirect services like consultation, mental health
education etc.

Types of Mental Illness
Major illnesses are called psychoses (out of touch with reality). Major
illnesses are:
SCHIZOPHRENIA (Split Personality) – pt lives in a dream world of his
own.
MANIC DEPRESSIVE PSYCHOSES – symptoms vary from heights of
excitement to depths of depression.
PARANOIA – extreme suspicion & progressive tendency to regard the
whole world in a framework of delusions.

Types of Mental Illness
Minor illnesses are 2 groups:
NEUROSIS OR PSYCHONEUROSIS - pt is unable to react normally to
life situations. Peculiar symptoms may occurs e.g. morbid fears,
compulsions, obsessions.
PERSONALITY & CHARACTER DISORDERS – legacy of unfortunate child
hood experiences and perceptions.

Mental disorder
•A mental disorder, also called a mental
illness, psychological disorder or psychiatric
disorder, is mental or behavioral pattern
that causes either suffering or a poor ability
to function in ordinary life.

Behavior disorder
•Emotional and behavioral disorders (EBD) is a
broad category which is used commonly in
educational settings, to group a range of more
specific perceived difficulties of children and
adolescents.

Introduction
• Many factors are responsible for the causation of mental illness. These
factors may predispose an individual to mental illness, precipitate or
perpetuate the mental illness.

Predisposing factors
• Predisposing factors exist in the individual. These factors determine
an individual susceptibility to mental illness. They interact with
precipitating factors resulting in mental illness. These predisposing
factors are:
Genetic makeup: is the study of heredity
Physical damage to the central nervous system
Adverse psychological influences

Precipitating factors (or exciting factors)
• These are events that occur shortly before the onset of a
disorder and appear to have induced it. Eg. death of
loved one.

• Physical Factors: These include infections, intoxications, endocrine,
circulatory, nutritional disturbances and trauma.
• Infections and Toxins: patients with hyperpyrexia, pneumonia, typhoid,
scarlet fever, influenza, septicemia and syphilis.
• Trauma: a fall from a height, forceps delivery or road traffic accident, a
result of rape, natural disaster or loses.
122/16/2020 Chetraj Pandit

Thus etiological factors of the mental illness can be grouped as
follow:
• Biological factors
• Physiological factors
• Psychological factors
• Social factors

Biological Factors include:
• Heredity
• Biochemical factors
• Brain damage

Heredity:
• What one inherits is not
the illness or its symptoms,
but a predisposition to the
illness, which is determined
by genes that we inherit directly. Studies have shown that three
fourths of mental defectives and one third of psychotic
individuals owe their condition mainly to unfavourable heredity.

Physiological Factors:
• puberty,
• menstruation,
• pregnancy,
• delivery,
• puerperium and
• climacteric.
• These periods are marked not only by physiological (endocrine) changes
but also by psychological issue that diminish the adaptive capacity of the
individual. Thus individual becomes more susceptible to mental illness
during this period.

Introduction
• The clinical manifestations are the end products of various
forces of internal conflicts of the individual. The intensity and
persistence of symptoms will indicate manifestation of the
disease.

Signs and Symptoms of Mental Illness
1. Alterations of personality and behaviour
2. Alteration in the level of consciousness
3. Alterations of Biological Functions
4. Disturbances in Mental Functions:
5. Changes in individual and Social Activities:
6. Somatic complaints:
7. Disturbances in motor behaviour:

1. Alteration in the level of consciousness:
• may be in fully conscious, semiconscious, lethargic,
somnolence, stupor, and coma.
• Conscious: fully alert, aware of time, place and person.
• Semiconscious: forgetfulness of an events or a person for a
while, later remembers the situation.

• Lethargy: aware of stimuli, dull senses, and slow responses.
• Somnolence: rarely awake, hardly aware of environmental
stimuli.
• Stupor: occasionally aware of environmental stimuli, forceful
stimuli needed to bring awareness.
• Coma: unconscious, variable response to stimuli,
incontinence of faeces and urine.
• Facial expression: dull, not interested.

2. Disturbances in bodily functions
• Sleep
• Appetite and food intake
• Biological function
• Sexual desire and activity

• Sleep:
• Disturbed sleep throughout the night, or
• no sleep at all, or
• difficulty in falling asleep, or
• waking up in the middle of night and failing to asleep again.
• lethargy and lack of freshness in the morning.

• Appetite and food intake: Increased or decreased appetite,
weight loss or weight gain, nausea, vomiting.
• Biological function:
• Diarrhoea and constipation, increased micturation, bed
wetting.
• Persistent deviation in temperature, pulse and respiration,
headache, pain, fatigue.

• Sexual desire and activity:
• Decreased interest in sex,
• premature ejaculation,
• impotence or lack of sexual satisfaction.
• In some condition there can be excessive sexual desire or
lack of social inhibitions.

3. Disturbances in Mental Functions:
• Behaviour
• Speech
• Thought
• Emotions
• Perception
• Attention and concentration
• Memory
• Intelligence and judgement
• Insight:

• Behavior:
• over activity, restlessness, irritability, may be abusive (for
trivial or no responses at all)
• dull, withdrawn and not respond to external and internal
cues.
• Sometimes the patient’s behaviour can be dangerous to self
or others.

• Speech:
• talks excessively and unnecessarily or talks very little or
stays mute.
• talk becomes irrelevant and un-understandable (in
coherent).

• Thought:
Patient expresses peculiar and wrong beliefs which other do
not share.
• Emotions:
• Patient may exhibit excessive emotions like excessive
happiness, anger, fear, or sadness.
• Sometimes emotions can be inappropriate to situations (laugh
to self or weep without any reason).

• Perception:
The patient may perceive without any stimulus. There can be
misinterpretation of perception.
• Hallucinations (see things or hear sounds or feel objects which
do not exist or others do not see). -Auditory, visual.

• Illusion (misperception of external stimuli)
• Delusions (false, unshakable belief which is firmly held on
inadequate grounds not affected by rational or logical
arrangements) are of examples.

• Attention and concentration:
• decreased attention and concentration:
• he/she may get distracted easily, or
• have selective in attention.
• Memory: Patient may lose his memory and start forgetting
important matters.

•Intelligence and judgement:
•Deteriorating in intelligence and judgement.
•loses reasoning skills and abilities (may not be able to
perform simple arithmetic or commits mistakes in
routine work).
• Insight: Insight may be absent or present

4. Changes in individual and Social Activities:
• may neglect their bodily needs and personal hygiene.
• lose social sense.
• behave in an inappropriate manner in social situations and
embarrass others.
• They behave strangely with their family members,
friends, colleagues and others.

5. Somatic complaints:
Patients may complaint of body aches and pains in different parts
of the body, fatigue, weakness, and involuntary movements.
6. Disturbances in motor behaviour:
Motor retardation, stupor, stereotypes, negativism, waxy
flexibility, echoprexia, restlessness, agitation and excitement.

DEMENTIA

DEMENTIA
• Dementia is an acquired global impairment of intellectual, memory, and
personality but without impairment of consciousness.
• Alzheimer's disease is the most common cause of dementia.
• About the half of these disorders are of the Alzheimer’s type.

Prevalence of Dementia
• About 5% of persons older than 65 years have severe dementia,
• 20% of persons older than 80 years have severe dementia and 30% of
those > 85.
• Alzheimer's disease accounts for > 65% of dementias in the elderly.
• Alzheimer's disease is twice as common among women than men

Etiology of Dementia
1. Degenerating and irreversible causes
• Alzhemier’s disease ( most common of all dementing illness)
• Pick’s disease (atrophy in the frontal and temporal lobes of the brain)
• Huntington’s chorea (damage in the area of the basal ganglia and the cerebral
cortex)
• Parkinson’s disease

Etiology of Dementia…
2. Reversible causes
• Lesions in intracranial space.
• Metabolic disorder: Hepatic failure, renal failure.
• Endocrine disorder: Myxedema, addison’s disease.
• Infections- AIDS, Meningitis, encephalitis.
• Intoxication: Alcohol, heavy metal (lead, arsenic), chronic barbiturate poisoning.
• Anoxia: Anaemia, post anesthesia, chronic respiratory failure.
• Vitamin deficiency: Thiamine and nicotine vit B3.
• Miscellaneous: Heatstroke, epilepsy electric injury.

Etiology of Dementia…
3. Risk factors:
• Age: The risk of dementia goes up significantly with advancing age.
• Genetics/family history:
• Cholesterol: High levels of low-density lipoprotein (LDL) increase a person's risk of
developing vascular dementia.
• Diabetes:
• Smoking and alcohol use, atherosclerosis, down syndrome etc.

CLINICAL FEATURES
• Personality changes: lack of interest in day to day activities, easy mental
fatigability
• Memory impairment:
• Cognitive impairment: disorientation, poor judgment, decreased attention
span, or difficulty in abstraction.
• Affection impairment: Labile mood, irritableness
• Behavioral impairment: Stereotyped behavior, alteration in sexual drives
and activities.

CLINICAL FEATURES…
• Neurological impairment: seizures, headache
• Catastrophic reaction: Agitation, attempt to compensate for defects by
using strategies to avoid demonstrating failures in intellectual
performances, such as changing the subject.
• Sundowner syndrome: It is characterized by drowsiness, confusion, ataxia,
accidental falls, may occur at night.
• Course and prognosis: Insidious onset (more than 4 wks) but slow
progressive deterioration occurs.

TREATMENT
• Symptomatic treatments
• Cholinesterase inhibitors (e.g. donepezil 5-10 mg per oral once a day,
rivastigmine 1.5-6 mg per oral bid, galantamine 4-12 mg per oral bid)
• Benzodiazepines for insomnia and anxiety
• Antidepressants for depression
• Antipsychotics to alleviate hallucinations and delusions
• Anticonvulsants to control seizures

DELIRIUM

DELIRIUM
• Delirium is an acute organic mental disorder characterized by impairment of
consciousness, disorientation and disturbances in perception and restless.
Delirium is a syndrome not a disease
Epidemiology:
• 0.4% in general population,
• 1.1% in population of aged >55 years,
• 9–30% in general hospital admissions and
• 5–55% in elderly general hospital admissions, about
• 10-25% of medical surgical inpatients.

DELIRIUM
Etiology
• Vascular: Hypertensive encephalopathy, Cerebral
arteriosclerosis, Intracranial haemorrhage
• Infections: UTI, pneumonia, ulcer, sepsis, meningitis
• Neoplastic: Space occupying lesions

Etiology of Delirium…
• Drugs intoxication:
• Traumatic: Subdural and epideural hematoma, contusion, laceration
• Vitamin deficiency: Thiamine, niacin, pyridoxine, folic acid, B12
• Endocrine and metabolic:
• Anoxia: Anaemia, pulmonary or cardiac failure
• Metals: Heavy metals, carbon monoxide and toxins

Clinical Features of Delirium
• Impairment of consciousness: clouding of consciousness
• Impairment of attention
• Perceptual disturbances: most often visual
• Disturbances of cognition: Disorientation and impairment of immediate
and recent memory, impairment of abstract thinking.

Clinical Features of Delirium…
• Psychomotor disturbances: Hypo or hyperactivity, aimless groping or
picking at the bed clothes
• Disturbances of the sleep wake cycle: Insomnia
• Emotional disturbances: depression, anxiety, fear, irritability, euphoria

Course and prognosis
• The onset is usually abrupt.
• The duration of an episode is usually brief, lasting for about a week.

Differences between Delirium and Dementia
SN Features Delirium Dementia
a Onset Usually Acute Usually Insidious
b Course Usually recover in 1 week Usually prolonged
c Clinical Features
1 Consciousness Clouded Usually normal
2 Orientation Grossly disturbed, disoriented Usually normal, Disturbed
only in late stage
3 Memory Immediate retention and recall
disturbed
Immediate retention and recall
normal
Recent memory disturbed.
Remote memory disturbed
only in late stages

4 Comprehension Impaired Impaired only in later stage
5 Sleep Wake cycle Grossly disturbed Usually normal
6 Attention and
concentration
Grossly disturbed Usually normal
7 Diurnal Variation Sun downing present Usually normal in early stage, sun
downing present in later stage
8 Perception Visual illusion and
hallucination present
Hallucination may occur.

Prevention and treatment
Physical Interventions:
• Immediate correction eg. 50mg of 50% dextrose IV for hypoglycemia,
oxygen for hypoxia, IV fluids for fluid and electrolyte imbalance
• Environmental stimulation
• Cognitive Interventions: Place a clock and a calendar where the patient
can see them easily. Verbally reorient to time and place several times
over the course of the day.
• Psychological Interventions

TREATMENT
Pharmacologic Interventions
• 100 mg of Vitamin B1 IV for thiamine deficiency and IV fluids for fluid
and electrolyte imbalances
• Symptomatic measures: Benzodiazepine (Lorazepam or diazepam) or
antipsychotic (Haloperidol or rispiridon) may be given.

community mental health

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to community mental health

Similar to community mental health (20)

More from chetraj pandit

More from chetraj pandit (8)

Recently uploaded

Recently uploaded (20)

community mental health

Editor's Notes