Unit-12: Community mental health nursing

Community mental health is a field of study which focuses on the prevention of mental illness
promotion of mental health, treatment of mental disorder and rehabilitation of mentally ill client
in the community. Community mental health is a decentralized pattern of mental health, mental
health care, or other services for people with mental illnesses. Community-based care is designed
to supplement and decrease the need for more costly inpatient mental health care delivered in
hospitals. Community mental health care may be more accessible and responsive to local needs
because it is based in a variety of community settings rather than aggregating and isolating
patients and patient care in central hospitals
The WHO states that community mental health services are more accessible and effective, less
social exclusion and are likely to have less possibility for the neglect and violations of human
rights that were often encountered in mental hospital.

Definition
Community Mental Health nursing
Community mental health is the application of knowledge of psychiatric nursing in preventing,
promoting and maintaining mental health of the people to help in early diagnosis and care and to
rehabilitate the clients after mental illness.
(Kapoor Bimala, 2002)

Purposes of Community Mental Health Programme

• To provide preventive activities to community people for the purpose of promoting

mental health.
• To provide intervention as early as possible.
• To prevent long stay of hospitalization and reduce the financial burden to the family.
• To help to reintegrate back into society as early as possible
• To reduce social stigma / discrimination related to the mental illness.
• To involve family members/ care takers in providing care to the mentally unhealthy
people
• To assist in providing mental health education to population about mental health and
to teach people how to assess their mental health.
• To promotion of community awareness regarding mystery of mental illness

Element of CMH
• Inpatient service
• Outpatient service
• Partial hospitalization
• Emergency services
• Diagnostic services
• Pre care and after care services including foster home placement and home visiting
• Education services
• Training
• Research and evaluation
Community Mental health care includes
• Mental health promotion
• Stigma removal
• Psychosocial support
• Rehabilitatory services
• Prevention of harm from alcohol and substance abuse
• Treatment of the ill, using primary health care system.

Trends of care: de- institutionalization

The process of transferring the mentally ill clients from hospital to the community is called
deinstitionalization. Deinstitutionalization means (1) avoiding mental hospital admissions
through the provision of community treatment alternatives, (2) the released in to the
community of all institutionalized patient who have given adequate preparation for such a
change, and (3) the establishment and maintenance of community support systems for non
institutionalized people.The goal of deinstitutionalization was to improve the quality of life for
people with mental disorders by providing services in the communities where they lived rather in
large institutions.

Deinstitutionalization works in two ways

• To change the locus of care, large hospital wards were closed and persons with severe
mental disorders were returned to the community to live. So this tried to decrease the gap
between the mentally ill clients and the community. The first focuses on reducing the
population size of mental institutions by releasing patients, shortening stays, and reducing
both admissions and readmission rates.
• The second focuses on reforming psychiatric care to reduce (or avoid encouraging)
feelings of dependency, hopelessness and other behaviors that make it hard for patients to
adjust to a life outside of care.

The goal of deinstitutionalization:

• To prevent long stay of hospitalization
• To make easier for the patient in community
• To make the treatment cheaper, easier and accessible
• To prevent long term disability and develop independency
• To reduce family burden in terms of financial and time.
• Public Health model of care
• Prevention of mental disorder is a public health priority. About 450 million people suffers
from mental and behavioral disorders worldwide.

Positive effects of Deinstitutionalization

• Allow for the integration of family and social system in care of patient.
• Better care would be provided to mentally ill patient in their home communities
surrounded by those who were not mentally ill.
 • It was a huge step in returning a sense of worth, ability and independence to those who
had been dependent on other for care
• They learned adaptive skills and receive better care.
• It gave the mentally ill many of their rights back that they had originally lost.
• It placed an emphasis on community resources for treatment.
• It focused on treating the “untreatable.”

Negative Effects of Deinstitutionalization

• Many people are not receiving the treatment they need, such as other general medical
treatment
• Many of those who went to community centers for treatment were not good candidates
for it.
• There is highly chances of noncompliance with medicine among the admitted patient
because of poor medical supervision
• Patient with severe and persistent mental illness not receiving adequate care commit
suicide.
• Deinstitutionalization made it impossible for people with severe mental illness to find
appropriate care and shelter, resulting in homelessness
• Early mortality due to lack of adequate medical facilities and supplies.

One person in four will develop one or more of these disorder during their lifetime.
Neuropsychiatric conditions account for 13% of the total Disability. Adjusted Life
Years(DALYs) lost due to all diseases and injuries in the world and are estimated to increase to
15% by the year 2020.
Five of the ten leading causes of disability and premature death worldwide are psychiatric
conditions. Mental disorders represent not only an immense psychological, social and economic
burden to society, but also increase the risk of physical illnesses.

PREVENTIVE PSYCHIATRY
Public Health Model
• The premise of the model of public health is based largely on the concepts set forth by Gerald
Caplan (1964) during the initial community mental health movement.

• They include:
• primary prevention,
• secondary prevention,
• tertiary prevention.
In modern day, four level of prevention

Public Health Model of Care

• In Caplan’s Principles of Prevention Psychiatry
 • prevention was subdivided into three categories: primary, secondary and tertiary
(Caplan, 1964).
• Primary prevention was defined as “an intervention designed to decrease the number of
new cases of a disorder or illness;”
• secondary prevention was defined as “an intervention designed to lower the rate of
established cases of a disorder or illness,” and
• tertiary prevention was defined as “an intervention designed to decrease the amount of
disability associated with an existing illness”

Level Of Prevention
Many people regard prevention of mental disorders as a desirable goal that should be actively
pursued. The prevention of mental illness is based on the public health principles and has divided
in to three types.

Primordial Prevention
• Prevention of emergence or development of risk factors
•Main intervention in primordial prevention is through individual and mass education

Primary Prevention
• Services aimed at reducing the incidence of mental disorders within the population.
• Targets both individuals and the environment. Emphasis is two-fold:
• Assisting individuals to increase their ability to cope effectively with stress.
• Targeting and diminishing harmful forces (stressors) within the environment.

Roles of Nurses in Primary Prevention

Individual centered intervention

• Antenatal care to the mother and educating her regarding the adverse effects of
irradiation, certain drugs and prematurity.
• Ensuring timely and obstetrical assistance to guard against the ill effects of anoxia and
injury to the new born at birth.
• Correction of endocrine disorders.
• Liberalization of laws regarding termination of pregnancy, when it is unwanted.
• Training programs for physically, mentally handicapped children like blind, deaf, mute
and mentally subnormal etc.

• Counselling the parents of physically and mentally handicapped children, with particular
reference to the nature of defects. The parents need to accept and emotionally support the
child and be satisfied with limited goals in the field of achievement.
• Fostering bonding behaviours: Explaining importance of warm, accepting, intimate
relationship, avoiding the prolonged separation of mother and child are essential.
Intervention oriented to the child in school
• Teaching growth and development to parents and teachers.
• Identifying the problems of scholastic performance and emotional disturbances among school
children and giving timely intervention. School teachers can be taught to recognize the beginning
symptoms of problems and referring to appropriate agencies.

Family centered interventions to ensure harmonious relationship

• Consulting with parents about appropriate disciplinary measures.
• Promoting open health communication in families.
• Rendering crisis counseling to the parents of physically and mentally handicapped
children.
• Ensuring harmonious relationship among members of family and teaching healthy
adaptive techniques at the time of stress producing events.

Interventions oriented to keep families intact

• Extending mental health education services at Child Guidance Clinics about child rearing
practices.
• Strengthening social support for frustrated aged and helping them to retain their usefulness.
• Promoting educational services in the field of mental health and mental hygiene.
• Developing parent teacher associations.
• Providing marital counseling for those having marital problems.
• Rendering home maker services-when there is absence of the mother from home due to illness
or other reasons for prolonged periods.

Interventions for families in crisis

• In developmental crisis situations such as the child passing through adolescence, birth of a new
baby, retirement or menopause, death of a wage earner in the family etc.

Mental health education

• Conduct mass health education programs through film show, flash cards and appropriate audio-
visual aids regarding prevention of mental illness and promotions of mental illnesses and
promotion of mental health in community.
• Educate health workers regarding prevention of mental illness so that they can function
effectively in all the areas of prevention.

Society-centered preventive measures

• Community development-culturally deprived families need biological and psychosocial
supplies. They need better hygienic living conditions, proper food, education, health facilities
and recreational facilities. Otherwise psychopathy, alcoholism, drug addiction, crime and mental
illness, will result in such situation.

Secondary Prevention
Secondary prevention targets people who show early symptoms of mental health disruption but
regain premorbid level of functioning through aggressive treatment.
• Services aimed at reducing the prevalence of psychiatric illness by shortening the course
(duration) of the illness.

• It is accomplished through early identification of problems and prompt initiation of effective

treatment. Nursing in secondary prevention focuses on recognition of symptoms and provision
of, or referral for, treatment.

Role of Nurse in Secondary Prevention

• Early diagnosis and case finding

• Early reference
• Screening programs
• Early and effective treatment for the patient
• Training of health personnel
• Consultation services
• Crisis intervention

Tertiary Prevention
• Services aimed at reducing the residual defects that are associated with severe and persistent
mental illness.
• It targets those with mental illness and helps to reduce the severity, discomfort and disability
associated with their illness.

It is accomplished in two ways:

• Preventing complications of the illness.
• Promoting rehabilitation that is directed toward achievement of each individual’s
maximum level of functioning.

Nurses Role in Tertiary Prevention

• Provide continue care
• Consideration of the rehabilitation process at the time of initial diagnosis and treatment
planning.
• Teaching the client daily living skills and encouraging independence to his or her
maximum ability.
• Referring clients for various aftercare services
• Monitoring effectiveness of aftercare services (e.g., through home health visits or follow-
up appointments in community mental health centres)
• Making referrals for support services when required.
• Involving family members in the treatment program so that effective follow up can be
ensured.
• Occupation and recreational therapy can be done so that idling can be prevented.
 • The nurses in community are in key position to monitor community attitudes and help in
fostering a realistic attitude towards mentally ill.
• Communication
Mental Health Promotion
Mental health promotion activities imply the creation of individual, social and environmental
conditions that enable optimal psychological and psychophysiological development. Such
initiation involves individuals in the process of achieving positive mental health, enhancing
quality of life and narrowing the gap in health expectancy between countries and groups. It is an
enabling process, done by with and for the people. Prevention of mental disorders can be
considered one of the aims and outcomes of a broader mental health promotion strategy.
(Hosman &Jane –Llopis 1999)

Mental health promotion interventions vary in scope and include strategies to promote the mental
wellbeing of those who are not at risk, those who are at increased risk and those who are
suffering or recovering from mental health problems.
Improving mental health and reducing the burden of mental illnesses are complementary
strategies which, along with treatment and rehabilitation of people with mental disorders,
significantly improve population health and well-being (WHO, 2005). The distinction between
mental health promotion and mental disorder prevention lies in their targeted aims.
The aim of mental health promotion is to promote positive mental health by increasing
psychological well-being, competence and resilience, and by creating supportive living
environments.
It is a process aimed at changing environments (social, physical, economic, educational,
cultural) and enhancing the 'coping' capacity of communities, families and individuals by
conveying knowledge, skills and the necessary resources.
The goal of mental disorder prevention is the reduction of symptoms and ultimately of the
mental disorder. Caplan's (1964) application of the concepts of primary, secondary, and tertiary
prevention, which are common in a public health context, had an influence in developing early
prevention models.
This conventional classification of prevention is based on the assumption that there is an
understanding of the linkage of the mechanisms that cause a disease with the occurrence of the
disease.
Mental health Promotion model

• levels of preventive interventions recommended by the institute of medicine (mrazek

& haggerty, 1994)

• Universal: Targets the general public or a whole population group that has not been
identified on the basis of individual risk. The intervention is desirable for everyone
• Selective: Focuses on individuals or a subgroup of the population whose risk of
developing mental disorders is significantly higher than average. The risk may be
imminent or it may be a lifetime risk.

• Indicated: Targets high risk individuals who are identified as having minimal but
detectable signs or symptoms of a mental disorder but who do not meet currently full
criteria for a diagnosis

Universal Preventive Interventions

The Life Skill Training Program (LST)

The LST is a classroom-based program designed to prevent adolescents from engaging in alcohol
use, drug use, and violent behavior. The LST is designed to teach students self-management
skills, social skills, and drug-resistance skills, and has been associated with short- and long- term
reductions in tobacco use, alcohol use, illicit-substance use, poly-substance abuse, violence, and
delinquency.
The positive action program
This is a school-based program designed to enhance social-emotional learning and positive
behavior in elementary and middle school students (aged 5 to 13 years). The classroom
component teaches self-management skills as well as strategies to increase the use of positive
social behavior.
The Positive Action Program has been associated with a reduction in suspensions and
absenteeism, in substance use, violence, and sexual activity, increased rates of socio-emotional
development, higher life satisfaction, reduced rates of depression and anxiety, reduced rates of
unhealthy food consumption, as well as overall improvements in school quality (Washburn et al,
2011).

The promoting alternative thinking strategy

The (PATHS) program is school-based also and is designed to reduce aggression and promote
emotional and social competencies in children grades K-6 (5 to 11 year olds).The PATHS
intervention targets five domains: self-control, emotional understanding, positive self-esteem,
relationships, and interpersonal problem-solving skills. This intervention attempts to involve
parents by incorporating home activity assignments and providing parents with information.

Project towards no drug abuse

Project TND is a drug prevention program for high school students who are at risk for substance
use and violent behavior. Project TND is designed to enhance self-control, communication,
resource acquisition, and decision-making. Project TND has been implemented as a universal
preventive intervention in general populations as well as a selective preventive intervention
among high-risk students.

Elective Or Indicated Preventive Interventions

Nurse Family Partnership (NFP)
The NFP is a maternal health program which provides home visitation for first-time, low-income
mothers by maternal and child health nurses. The intervention is designed to improve pregnancy
outcomes, improve infant health, promote infant development, and improve the mother’s life-
course trajectory. In particular, during pregnancy, the NFP is designed to eliminate cigarette-,
alcohol-, and drug-use, and encourage exercise, and sound personal hygiene habits (Olds et al,
1997).

New Beginnings
The New Beginnings program is an intervention for divorced mothers with children ranging in
age from 5 to 18. This is a parent-driven intervention designed to help mothers engage in
effective child behavior management strategies, enhance the quality of mother-child interactions,
and reduce children’s exposure to interparental conflict. Among children, the New Beginnings
program has been associated with decreases in internalizing, externalizing, and aggressive
behaviors (Wolchik et al, 1993; 2000). With respect to family dynamics, the New Beginnings
intervention has been associated with improvements in the use of effective discipline strategies,
parent-child communication, and positive routines (Wolchik et al, 1993).
Treatment Foster Care Oregon (TFCO)
The TFCO is a 6-month intervention for adolescents with a history of antisocial behavior,
emotional disturbance, and delinquency. Foster families from the community are recruited and
trained to provide adolescents with clear and consistent limits, appropriate consequences, and
positive reinforcement for appropriate behavior. In so doing, the TFCO system also provides
adolescents with a mentoring adult and separation from delinquent peer group.

Multisystemic Therapy (MST)

MST is a family and community based intervention designed to improve antisocial behavior
patterns in adolescent juvenile offenders. MST works across multiple settings (i.e., home, school
and community) to increase prosocial behavior and decrease antisocial behavior.

Multisystemic Therapy-Problem Sexual Behavior (MST-PSB)

Similar to the broader MST, MST-PSB focuses on the family, school, peer, and community
systems in which an adolescent is embedded in order to reduce antisocial behavior. However,
MST-PSB concentrates specifically on the dimensions of the youth’s environment that are related
to problematic sexual behavior.

The Blues Program

The Blues Program is a group cognitive-behavioral intervention for adolescents with prodromal
symptoms of depression. The program seeks to provide social support and helps adolescents
restructure maladaptive thoughts, develop plans to respond to future stressors, and participate in
pleasant activities.

The Body Project

This is a 4-week group intervention designed for high school and college aged females with
disordered eating. The Body Project engages participants in body acceptance exercises and
teaches strategies to avoid peer pressure.

Brief Alcohol Screening and Intervention for College Students (BASICS)

BASICS consists of a two-session intervention designed for individuals aged 18-24 who are at-
risk for alcohol use disorders. BASICS seeks to help college-aged students better understand the
risks associated with drinking, enhance motivation to change, develop skills to drink moderately,
and ultimately make better alcohol-use related decisions.

Functional Family Therapy (FFT)

This is a family-based intervention targeting delinquent adolescents and their families. FFT is
designed to enhance parenting skills, youth compliance, family communication and
supportiveness, while decreasing negativity and dysfunctional behavioral patterns

Parent-Management Training-Oregon Model (PMTO)

The PMTO is a group-based parent training intervention for the parents of children ranging in
age from early childhood to late adolescence. PMTO is designed to enhance effective family
management skills and thereby reduce antisocial and problematic behavior in children.
Research suggests that PMTO is associated with reductions in coercive parenting,
noncompliance, and negative reinforcement, and increases in effective and positive parenting
(Forgatch & DeGarmo, 1999)

Promotion of mental health of adolescence

8 September 2020 - New guidelines from WHO recommend a set of psychosocial interventions
to promote mental health and prevent mental health conditions among adolescents, aged 10-19
years.
The recommendations are based on the results of intervention studies – both universal, delivered
to all adolescents; and for selected individuals perceived to be at risk of mental health conditions.
They will help inform the development of policies and programmes for the improved mental
health of young people.
Particular attention is given to: adolescents at increased risk of mental disorders or self-harm due
to exposure to adversity; adolescents going through challenging life circumstances such as
adolescent pregnancy; and those with early signs or symptoms of emotional or behavioural
problems.
The interventions recommended can be delivered in school and community settings and through
digital platforms.
• Mental health is a major issue for adolescents: up to half of all mental health conditions
start before the age of 14.
• Poor mental health is the leading cause of disability in young people, and accounts for a
large proportion of the global disease burden during adolescence. Suicide is the third
leading cause of death in 15-19-year-olds.

• And it has long-term impacts. Poor mental health in adolescence is one of a number of
factors influencing risk-taking behaviour, including self-harm; use of tobacco, alcohol
and drugs; risky sexual behaviours; and exposure to violence. The effects of all these
persist and can have serious implications throughout life.
• Young people are facing increasingly complex social, cultural and economic
environments, with challenges resulting from changing family environments,
employment instability and unemployment in their households, and in some countries
forced displacement.
• Young people from minority and migrant communities are affected disproportionately by
mental health conditions. Adolescent girls are twice as likely as adolescent boys to be
affected by common mental disorders.

• Sociocultural factors, such as lower education levels, poverty, exposure to domestic

violence and abuse and low decision-making power tend to increase the risk of
depression in girls and women.

WHO and UNICEF are developing a toolkit to facilitate the implementation of the new
guidelines. The kit will include strategies for both supportive policies and laws and
implementation of interventions in different settings.
Note:
• These guidelines address interventions for the promotion of mental health and prevention
of mental health conditions in adolescents. They do not address the treatment,
pharmacological or otherwise, of diagnosed mental health conditions.

 Globally, one in seven 10-19-year-olds experiences a mental disorder, accounting for 13%
of the global burden of disease in this age group.
 Depression, anxiety and behavioural disorders are among the leading causes of illness and
disability among adolescents.
 Suicide is the fourth leading cause of death among 15–29-year-olds.
 The consequences of failing to address adolescent mental health conditions extend to
adulthood, impairing both physical and mental health and limiting opportunities to lead
fulfilling lives as adults.

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