Community mental health: Matters arising

Community mental health: Matters arising

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Community mental health services support or treat people with mental health difficulties in a domiciliary setting instead of a psychiatric hospital. It refers to a system of care in which the community is the primary provider of care for people with mental illness.

The World Health Organisation views the community mental health services as more accessible, more effective, lessen social exclusion and parade less possibility of neglect and violation of human rights that were often encountered in mental hospitals. However, the shift of treatment of the mentally ill to the community has not been accompanied by effective services in the community, thereby leaving a vacuum.

Following the process of de-institutionalisation in America, a shift in focus from treatment in the hospital to custodial care emerged. However, some of the mentally ill ended up in the streets as homeless individuals. It was at this point that modern community mental health services started to grow and became influential.

In 1955, the Mental Health Study Act was passed for an objective, thorough, nationwide analysis and re-evaluation of the human and economic problems of this new approach. In 1963, the Community of Mental Health Care Act was passed, thereby kick-starting the community mental health revolution with three main initiatives, namely: professional training for community mental health workers, improvement of research in the adopted methodology, and improving the quality of care of existing programmes.

The American government passed through several stages of fine-tuning this policy and committing substantial funds to the effective implementation. In 1977, the National Institute of Mental Health, with the equivalent status of a full-fledged federal ministry in Nigeria, initiated a community support programme comprising the following elements, namely: responsible team, residential care, emergency care, medicare, halfway house, supervised apartments, outpatient therapy, vocational training and opportunities, family and social networking. This conceptualisation has come to serve as the template for modern day community mental health service development.

Several other acts were passed by government to enable other stakeholders like the state and local governments to participate and tackle emerging problems, especially of those of cost and accommodation.

The underlying assumptions of this innovation require that patients who are treated in the community have a place to live and have a supportive social network that does not inhibit rehabilitation. Experience however has shown that many people with mental illness who, upon discharge, have no family to return to, end up homeless. Jails became alternative accommodation for those arrested for various crimes.

With the astronomical rise in the number of persons diagnosed with a mental health or substance abuse disorder receiving treatment at the primary care posts, there was a spillover back into the mental hospitals.

Essentially, community services include supported housing with full or partial supervision, psychiatric wards in our general hospitals, local primary care, day centres, community mental health centres and self-help groups. These services may be provided by appropriate government institutions such as specialised teams providing services across a geographical area as it is done in most of our federal neuropsychiatric hospitals in Nigeria.

This effort is commendable but not sufficient to tackle the enormous burden of mental illness in our society, especially the apparent non-involvement of our state and local governments. The community mental health care programme is a useful template to bridge this gap but must be contextually assimilated.

In the developed countries, it is a response to the overcrowding of the mental hospitals, but the challenge here in Nigeria is to ensure that our patients, with the alternative mental health practitioners, are not abused and have access to effective, safe care.

The few patients who manage to enter orthodox care may default into the hands of the alternative mental health practitioners in the community, consequent on the interplay of economic and cultural forces. The challenge of community mental health care in Nigeria is to synergize the orthodox practice with the existing alternative mental health practitioners who could be traditional or spiritual resident in our communities and taking custody of a larger percentage of our patients, since a good number of them put our antipsychotic drugs in their native concoctions and holy water.

Although the accommodation provided for the alternative care are, most times, shoddy and therapeutic, methods adopted like flogging, fasting and other inhuman treatments could be improved in the training of the community mental health practitioners that would be involved with them. There are much more possibility of life- threatening practices in our alternative care centres than in our orthodox mental hospitals.

Faith-based organisations have great lessons to teach us in articulating effective community-based programmes like the CBM is championing in Enugu and Benue States in Nigeria and other West African countries. Overall, the challenge is not just for the government but for families, philanthropic clubs, foundations and our corporate organisations.

PUNCH.

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