community mental health nursing

COMMUNITY MENTAL HEALTH NURSING
INTRODUCTION:
Mental health is poorly understood by the common man, and is equated to the mental illness; thus the people think that so long as one is not mad, one is perfectly healthy. Just as in physical health there are varying degrees of health and no one is hundred percent healthy, so also in mental health there are varying degrees of adjustments, understandings and abilities to cope up with emotional problems. Optimum mental health is necessary for a healthy and successful life in all aspects. Mind is an integral part of our being. It has many functions take place on an harmonious way and at the optimum level, life is successful and happy.
DEFINITIONS
 Health:
Health is defined as a dynamic state of physical, mental, social and spiritual well being and mot mer4ely the absence of disease (WHO)
 Mental Health:
Mental health has been defined as “a state of balance between the individual and the surrounding world, a state of harmony between the realities of the self and that of other people and that of the environment”
 Community Mental Health:
Psychiatric / mental health nursing is the diagnosis and the treatment of human responses to actual or potential mental health problems. Psychiatric mental health nursing is a specialized of nursing practice, employing theories of human behaviour as ts science and purposeful use of self as its art”
Historical Development Of Community Mental Health Nursing
Transference:
The history of mental health services has been a gloomy, but nevertheless it has been taught as many as lessons. Past experience of mental health built a strong myth and perception in the community and the common man perceived mental illness as social stigma, admission in asylum or mental hospital, electric shocks and confinement in institution with sub human conditions. The picture has changed drastically and the modern mental health care goes for beyond the institutions and in a way it is trying to restore and build confidence of common man and by changing his / her perception through educational programme. Mass media continues to focus on miserable conditions of asylum and mental hospitals and sub human conditions of these hospitals, to draw the attention of authorities for improving these conditions. Directives of honorable Supreme Court have made substantial contribution in the area of mental health programme.
Legal impact:
The Indian lunacy act of 1912 has been replaced by 1987 mental health act with a focus to improve the quality of services / care and protect the rights of mentally ill. Mental health act has been a very important mile stone in development of modern psychiatric services in the country, hopefully the act is made patient friendly. The state governments took a long lead time to establish mental health authority and to implement this act.
National effort:
National mental health programme initiated in 1981 ahs ultimately come out with community based approach for sustainability of actions as also chanced accessibility development of district mental health programme is a step in the right direction but progress and coverage is too slow to make any mark on amelioration of the problem nodal agency has been identified in each state to undertake in service training programme of the medical officers and paramedical workers as also to provide technical support to district training programme.
Integration with general medicine:
It is recognized that effective delivery of primary health care including mental health care would largely depend upon the nature of education and appropriate orientation towards community health of all categories of medical and health personnel and their capacity to function as an integrated team. Basic training curricula of al categories should incorporate sufficient time for building essential skills of medical and paramedical personnel so that; they are able to deal with the problem of mental health within the framework of primary health care. In general, we must address the issues of quality of medical education for undergraduates and specifically to the training of students in the discipline of psychiatry to lay firm foundation for the development of mental health services as primary care level. This is considered as real investment in development of psychiatric health services in the community.
Education and training:
Training of trainers (TOT) is essential to impact the need based and relevant training on the key areas of mental health and counseling. Training needs assessment and perusing hands on the with care material and community should become the primary focus with trainees of medical and paramedical personnel. Medical education cell and state institute of health and family welfare can be on trusted with the task of training of trainees. National health policy and programme on mental health and its key strategies must be made available to the trainees.
In service training manual prepared by NIMHANS focuses largely on technical subjects and hospital based training, confirming an established impression that the solution to mental health programme lies in big hospitals and nothing worthwhile can be done / achieved at the community level. Substantial part of training of medical officers and paramedical personnel should be at the community level to focus on critical areas like role of community, institutions, family and individual to tackle mental health problems.
Focus of the training of necessity should be on the methods of interviewing and contact with the individual and families skills of listening to clients assessing there needs; counseling and identification of high risk families and clients as also group meetings and dynamics besides community organization and mobilization of resources containing should be a part of the routine meetings. Health team should be trained together for better understanding of each other’s roles and responsibility.
Public awareness:
Awareness generation and mental health literacy drives are the level of community through active involvement of panchayat raj institutions, influential groups, non formal bodies and other organized groups on regular basis can be most productive. Awareness generation campaign must have the support of district mental health services, community health centre, primary health centre and sub centre system. If the training programme and development of strategies are evolved far away from the real situation, this may create a negative impact and generate a sense of dependency and kills local initiatives.
Available services:
Even the available services for mental disorders are being poorly utilized. Nearly two third of persons with known mental disorder never seek help from health professionals and most clients utilize the services of other agencies. Mental health literacy needs to be built strongly in the community to scale up the utilization of the available mental health services.
The services and infrastructure for mental health services in public sector are inadequately and mostly confined to bigger cities and hospitals. District programme of mental health services has just taken off. Primary health care infrastructure on the other hand is reasonably well developed and is most universally accessible to rural and urban areas. Minimum package of mental health services for all can be best delivered through primary health care system. Preventive and promotive programme along with awareness generation can be undertaken on sustainable basis through this infrastructure.
System of integrated child development services (ICDS) and the institutions of anganwadis have been recognized as sheet anchor in personality development in young children. This is one of the finest examples of development of positive mind and mental health.
NIMHANS has rightly picked up ICDS system to involve them in national mental health services. They are being imparted 5 days of training programme at district level. Their training would be critical as these workers will serve as link between community and the formal health service system. Since anganwadi workers are locally resident voluntary, deeply rooted in the community they can be most effective in dissemination of knowledge on mental health programme besides identification of client’s at the3 earliest stage of morbidity, because of their continuous contact with the families. NPP envisages enlarging the sphere of ICDS to cover school going children upto the age of nine years. The in-service training on mental health should be undertaken by supervisors or trained child development programme officers and it should focus on child development, personality development and learning by play way activities.
Adolescent boys and girls who are the future parents need greater degree of mental health services to develop value based learning and balanced personality. Teachers along with parents can shape balanced personality. District mental health service programme should have incorporated this programme very strongly and entrust the responsibility of teachers training to district health teams. District mental health programme should not loose the opportunity, as it would be a real investment in preventive, promotive, and positive mental health or extended community mental health.
Government or public mental health services is just one source for mental health services, private sector and non-government organizations as also divorse the health care providers such as practitioners of Indian system of medicine should be considered as potential resource for primary health car including mental health services. There involvement can be increases the base of accessibility of services to masses. Partnership between government and private sector is an important area for the development of mental health services programme of community level.
It is widely acclaimed that community case is more effective as well as more humane that in – patient stays in mental hospitals, it is, therefore, essential to develop mental health services in the community settings has an integral part of primary health care; to root out stigma myths and misconceptions and discrimination against mental disorders.
NATIONAL MENTAL HEALTH PROGRAMME :(NMHP)
The government of India has launched the NMHP in1982, keeping in view the heavy burden of illness in the community and absolute inadequacy of mental health care infrastructure in the country deal with it. The programme envisages a primary health care community based approach in the rural areas supported by professional psychiatric supervision from the district levels and referral services by the mental hospitals and mental health units of the general hospitals.
Aims:
1. Prevention and treatment of mental and neurological disorder and there 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 equality of life.
Objectives:
1. To ensure availabilities and accessibility of minimum mental health care for all in the fore seeable 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 services development and to stimulate efforts towards self-help in the community.
Strategies:
1. Integrating mental health with primary health care through the NMHP.
2. Provision of tertiary care institution for treatment of mental disorder.
3. Eradication stigmatization of mentally ill patient and protecting their rights through regulatory instructions like the central mental health authority, state mental authority.

MENTAL HEALTH CARE:
• The Mental Morbidity Requires Priority In Mental Health Treatment:
Acute mental disorders of varying aetiology like acute psychosis, paranoid reactions, and psychosis associated with cerebral involvement as seen in communicable diseases like malaria, typhus, meningitis, alcohol psychosis and epilepsy psychosis resulting temporary disabilities can be treated.
Modern treatment of schizophrenia, dementia and encephalopathy reduce disability to great extent.
Emotional illness is often associated with physical disease and these patient do seek help at the general health services. Proper recognition and treatment is very important to reduce the morbidity in the community.
• Primary Health Care At Village And Sub-Centre Level:
Multi proper workers (MPW), and health supervisor will be trained to deal with management of psychiatric emergencies, maintenance of treatment advice from the higher centre, management of grand mal epilepsy through utilization of appropriate medicine under the guidance of medical doctor and liaison with the local school teachers and parents in matters concerning the management of children with mental retardation and beh
avior problems and counseling of alcohol and drug abuse.
• At Primary Health Centre Level:
Medical officers will be trained to provide following services:
1. Supervision of MPWS and health supervisors.
2. Producing mental diagnosis with help of flow chart and neurological examinations.
3. Treatment of mental disorders which can be managed at PHC and epidemiological, surveillance of mental disorders in the area, planning and implementation of programme for the same.
• At The District Hospital Level:
There is an urgent need for psychiatric specialty attached to every district hospitals with strength of 30-40 beds as an integral part of district health services. There should provision of admission, treatment of all kind of mental disorder, ECT and further referral services.
• Mental Hospitals And Teaching Psychiatric Units:
These higher centres of psychiatric care will actively and dynamically function with links to the periphery. This envisages a change in role of psychiatrists from a clinical specialists and planners of mental health services in his territory.

COMPONENTS:
1. Treatment: the treatment programme must be planned by keeping the primary health care has sheet anchor. At the same time it should consist of an appropriate referral system at various levels.
2. Rehabilitation: rehabilitation of psychiatric patients will be facilitated greatly by maintaining treatment of epileptics and psychotics at community level.
3. Preventions: this component of the service programme will be community based with only a united involvement of health service personnel.

LEVELS OF PREVENTION:
Three level of preventions have been described,
1. Primary:
Primary prevention operates on community basis. This consists of “Improving the social environment”: and promotion of the social, emotional and physical well being of all people. It includes working for better living conditions and improved health and welfare resources in community.
2. Secondary:
This consist of easy diagnosis of mental illness and of social and emotional disturbances through screening programmes in schools, universities, recreation centres, etc., and provision of treatment facilities and effective community resources. In this regard, “family based” health services have much role play. The family service agencies identify emotional problems and early symptoms of mental illness help family members tp cope up with overwhelming stress, treat problems of individual and social maladjustments when required and prepare individual family members for psychiatric care “care work” or “counseling” is the method most commonly employed by the family service agencies. The agencies, main responsibility is to provide a counseling service and help to families with marital conflict, disturbed parent- child relationship and strained IPR. Family counseling is one method of treatment interventions for helping the mentally ill.
Family counselors make an accurate psychosocial diagnosis.
3. Tertiary:
Tertiary prevention seek to reduce the duration of mental illness and thus reduce the stresses they create for the family and community. In short, the goal at this level is to prevent further breakdown and disruption.
MENTAL HEALTH SERVICE IN INDIA:
The current status of mental health services in India can be best understood by reviewing the development of the services in the last few decades.
1. In1946, the BHOR committee presented the situation in regard to mental health services, and the existing number of mental hospital beds during that time was in the ratio of one bed to about 40000 of the population. Following this committees report, five mental hospitals were set up.
2. Mudaliar health committee (1962) suggested that “arranging such that each region, if not each state, becomes self-sufficient in the matter of training its total requirement of mental health personnel”.
3. General hospital psychiatric units (GPHUS): though such units for mental ill persons were started as early as the 1930’s the major spurt came in the 1960’s. This period also coincides with the building of the first mental hospital in the country. These units provide a big support to the affected public without fear of social stigma.
4. Community care approach: this constitutes the next phase of development of mental health services. The impetus for this approach has come from:
 The commitment of the country to provide health services to all.
 The Alma Atta recommendation on primary health care.
 The existence of a large infrastructure for general health services, and
 The realization of the magnitude of severe mental disorders in the community.
ROLE OF NURSE IN COMMUNITY MENTAL HEALTH:
1. Social: Major function in caring for a mentally ill person:
 Meeting the needs of the patient or helping the patient to meet his own needs.
 Provide safe environment (physically and emotionally).
 Helping the patients to be emotionally in touch with reality and accepting the reality.
 Protecting the patient from his own behavior resulting from his illness.
 Creating an environment that provides corrective emotional experience.
 Helping the patient to improve his socializing skills.
 Educating the patient to handle anxiety and stress in every day life situations.
 Helping the patient, family and the community cope with mental health problems through continued supervision and guidance.
 Co-operating with the other health team members to plan and implement activities that are preventive and curative in nature.
2. Preventive work:
 Do not allow the mentally ill patient to marry and produce children.
 Do not allow marrying within the family even if the individuals are healthy.
 During pregnancy the mother should have proper food, recreation, rest and mental happiness.
 All forms of drugs, chemicals, alcohol and other intoxicants that will interfere with the normal development of the fetus, should be avoided.
CONCLUSION:
People and the community are the biggest resources available in India. Many of the problems in the area of mental health can be effectively dealt with by the people and within resources available close to them. Large scale disseminations of knowledge and simple skills to people and health volunteers should be addressed through primary health care. Capacity of family must be built and primary health care infrastructure should support the family to build their capacity to prevent and manage the mental health problems within the available means.
BIBLIOGRAPHY:

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 Indian Journal Of Community Medicine; Moving Away From The Mental Institutions Towards Community Mental Health Care; Vol XXVIII; No 4 Oct – Dec 2002; Page Number: 147-190.
 Kishore J; National Programmes Of India; 4th Edition; Century Publications, New Delhi; Pagenumber: 181-183.
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