COMMUNITY AND

HOSPITAL PSYCHIATRY

For Year III Psychiatry students

May 2024

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General objectives:

 At the end of the course:

Identify treatment and prevention methods
of mental illness (in the community)

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Specific Objectives: After completing this course the
students will be able to:-

1. Define community mental health

2. Discuss the significant events in the history of community
mental health
3. Identify the major concept of community mental health
4. Compare the different types of community support services.
5. Explain programs of an ideal community mental health
center
6. Describe the varied roles of the psychiatric practitioners in
community mental health
7. Discuss the role of hospitals in carrying out community
mental health service

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Brainstorming

 Discus with the person next to you

about:
 Community?
 Health?
 Mental health?
 Mental illness?
 Community mental health?
(using your own words)

No right, no wrong!
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Community

Different definitions:
1. the people with common interests living in a
particular area
broadly : the area itself
e.g. the problems of a large community (the shepherds, live in
the desert, hunters,….)
2. a group of people with a common characteristic
or interest living together within a larger society
e.g. a community of retired persons (HTN, DM,
3. a body of persons of common and especially
professional interests scattered through a larger
society
e.g. the scientific community
4. a body of persons or nations having a common
history
04/10/2025 or common social, economic, and political 5
Community, definition
cont’d…
a group of people living in the same
place or having a particular
characteristic in common (Oxford
dictionary)
 Synonyms
▪ Town
▪ Village
▪ City
▪ Society
▪ Residents…..
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 Community, definition
cont’d…
 The term community has two distinct
commutative meanings:
1. Community usually refers to a social unit
larger than a small village that shares
common values.
The term can also refer to the national
community or international community, and
2. In biology, a community is a group of
interacting living organisms sharing a
populated environment.

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Community, definition
cont’d…
 The word "community" is derived from the
Latin communitas (meaning the
same) (cum, "with/together" + munus,
“performing services"), a broad term for
fellowship or organized society.
 Some examples of community service are to
help in church, tutoring, hospitals, etc.

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What is health?

 Health is a state of complete

physical, mental and social well-
being and not merely the absence of
disease or infirmity’
(WHO, 1948),
https://iris.who.int/handle/10665/85573

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What is mental health?
 Mental health is a state of mental well-being that
enables people:
▪ To cope with the stresses of life,
▪ Realize their abilities,
▪ Learn well and work well, and
▪ Contribute to their community.
 It is an integral component of health and well-being
that underpins our individual and collective abilities
to make decisions, build relationships and
shape the world we live in.
(WHO)
(https://
www.who.int/news-room/fact-sheets/detail/mental-healt
h-strengthening-our-response
)04/10/2025 10
About Mental Health,
cont’d…
 Mental Health...involves effective
functioning in daily activities resulting in:
▪ Productive activities (such as in work, school or
caregiving)
▪ Healthy relationships
▪ Ability to adapt to change and cope with adversity
(APA)
(https://
www.psychiatry.org/patients-families/what-
is-mental-illness
)
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What is mental illness?

 Mental Illness...refers collectively to

▪ all diagnosable mental disorders — health
conditions involving:
Significant changes in thinking, emotion and/or
behavior or combination of them
Both/Either of Distress (pain full symptoms)
and/or impairment in functioning (in social,
work or family activities).

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What is community
mental health?
 Defines community mental health as
activities that promote mental health
that are performed in the community
instead of institutional settings.

(APA)

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 What is community mental
health? Cont’d…
Community mental health care comprises
the principles and practices needed to
promote mental health for a local
population by:

1) Addressing population-based
needs in ways that are accessible
and acceptable;

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What is community mental
health? Cont’d…

2) Building on the goals and

strengths of people who experience
mental illnesses;
3) Promoting a wide network of
supports, services, and resources of
adequate capacity; and
4) Emphasizing services that are
both evidence based and recovery-
oriented.
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 Community psychiatry

 it is psychiatric services to the patient within their community

environment
 It is a client-centered model
 It is a science and art of promoting mental health, preventing
mental illness, prolonging life through organized effort of society
 It focusing on the detection, prevention, early treatment, and
rehabilitation of patients with emotional disorders

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Community psychiatry,
Cont’d…
The WHO states that community mental health
services:
• Are more accessible and effective

• Lessen social exclusion

• Are likely to have less possibilities for the

neglect and violations of human rights

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 Objectives OF CMH
 Responsible to a community participation
 Being closer to the patient
 Mental health services should be provided to the patient at his home or place of

work
 Continuity of care:
 A therapist following a given patient through emergency services,

hospitalization and follow up in community

 Client-centered approach
 Avoidance of unnecessary hospitalization
 Evaluation and research

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Concepts of CMH

 Focuses on promoting mental health and rehabilitation.

 The principles of CMH include treating clients in their
usual environments when feasible, using a holistic
approach, and prioritizing cost-effectiveness
 They include primary prevention, secondary prevention and
tertiary prevention.
 These concepts relevance, not only to mental health, but
have been widely adapted as guiding principles in many
clinical and community settings over a range of medical and
nursing specialties

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THE PUBLIC HEALTH MODEL

 Itwas based largely on the concept

set forth by Gerald Caplan (1964)
during the initial community mental
health mov’t
 Include:
▪ Primary prevention
▪ Secondary prevention, and
▪ Tertiary prevention

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Primary Prevention

 Services aimed at reducing the incidence of mental disorders

within the population.
 Primary prevention targets both individuals and the environment.
 Emphasis is to:
1. Assisting individuals to increase their ability to cope effectively
with stress.
2. Targeting and diminishing harmful forces (stressors) within the
environment.

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Primary prevention is focused on

• Teaching parenting skills and child development to

prospective new parents.
• Teaching physical and psychosocial effects of
alcohol/drugs to elementary school students.
• Teaching techniques of stress management to virtually
anyone who desires to learn.
• Teaching groups of individuals ways to cope with the
changes associated with various maturational stages.
• Teaching concepts of mental health to various groups
within the community

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Secondary Prevention

 Interventions aimed at minimizing early symptoms of

psychiatric illness and directed toward reducing the
prevalence and duration of the illness.
 Is achieved through early identification of problems and
prompt initiation of effective treatment.
 Secondary prevention focuses on recognition of symptoms,
provision of care, or referral for treatment.

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 Tertiary prevention

It is reducing the residual defects that are associated with severe or

chronic mental illnesses accomplished in two ways:

1. Preventing complications of the illness.

2. Promoting rehabilitation that is directed toward maximum

achievement of each individual’s level of functioning

• These individuals may never have experienced hospitalization,

but they still do not possess adequate skills to live productive

lives within the community

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 Tertiary prevention focuses on

 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 (e.g. support
groups, day treatment programs, partial hospitalization
programs, psychosocial rehabilitation programs, group home
or other transitional housing)

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 Concepts of mental illness changed from
primitive times up to the 21st Century

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 HIPPOKRATES
460 – 370 B.C.

 Personality of humans

1. SANGUIN- FUNNY
2. FLEGMATIC- PASSIVE
3. CHOLERIC- HARD WORKER
4. MELANCHOLIC- DEPRESSED

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MIDDLE AGES

 ISOLATION OF MENTALLY ILL PEOPLE,

 SPECIAL MONASTERIES – ASYLUM
 PRISON
 TORTURE
 EXORCISM
 WITCH TRIALS

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ENLIGHTENMENT
17th – 18th CENTURIES
MODERN PSYCHIATRY – MENTAL DISORDERS
seen as MEDICAL DISEASES

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MODERN PSYCHIATRY
19th. CENTURY
 B. Morel (1809–1873) –
démence précoce - deteriorated
patients

 E. KRAEPELIN (1856 – 1925) –

DEMENTIA PRECOX
 E. BLEULER (1857 – 1939) –
SCHIZOPHRENIA
 4A’s – symptoms
 hallucinations and delusions

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 FIRST HALF OF THE
20th CENTURY

 1900 S. FREUD
-PSYCHODYNAMIC CONCEPTS
-TOPOGRAPHICAL MODEL OF THE
MIND

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SECOND HALF OF
THE 20th CENTURY

 1938 - ECT

 1952– CHLORPROMAZINE

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 21 CENTURY
st

 In 2 000 WHO - WORLD MENTAL HEALTH

DAY started to be celebrated.

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Mental health problems in Ethiopia

 Not systematically categorized as in modem

psychiatric nomenclature
 Recognized syndromes of mental illnesses in
traditional Ethiopian societies.
Such syndromes are given different names in different
ethnic languages.

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Mental health services in Ethiopia

 Currently, both the traditional and modem methods of

treatment are used by people. For:-

a) The deeply ingrained religious and inherited beliefs

that all mental illnesses are of spiritual origin, and

like their causations, their preventions and cure are
achieved via traditional healers.
b) Traditional healers are more accessible.
04/10/2025 35
Mental health services in Ethiopia,
cont’d...
c) The fees charge by traditional healers and the
cost of prescribed items are usually cheaper.
d) The orders of traditional healers are
symbolic and attractive. For example, a
person accept wearing an amulet, sprinkle,
dispatch,.. than tablets.
e) Traditional healers identify with the
population in their ways of living.

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ETHIOPIAN MODERN
PSYCHIATRY HISTORY
 The only hospital- Amanuel and JUMC
 The only rehabilitation place- Gefersa
 Number of psychiatrist few and most live in
Addis

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Why Study Psychiatry?

 Mental illness is common.

 In a given year:
 nearly one in five (19 %) U.S. adults experience
some form of mental illness
 one in 24 (4.1 %) has a serious mental illness
 one in 12 (8.5 %) has a diagnosable substance use
disorder
 The vast majority of individuals with mental
illness continue to function in their daily lives
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Why Study Psychiatry?, …
 Psychiatric disorders are prevalent and often
go untreated.

* lifetime prevalence in Ethiopia : 20%

 in general practice : 1/5 of the patients seen
have a psychiatric problem

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Why Study Psychiatry ?…
 Nearly half a billion people suffer from a mental
or behavioral disorders world wide.
 Over 150 million people suffer from depression
 37 million people from Alzheimer's Disease
 24 million people from schizophrenia
 10-20% of children
 Billions abuse substances
 800,000 people die from suicide each year

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Why Study Psychiatry ?…

 Mental disorders represent 2 of the 10 leading

causes of disability worldwide (2020).
 Mental and behavioral disorders account for 12%
of the global burden of disease.
 Mental health budgets of the majority of countries
constitute less than 1% of their total health
expenditures.
 There is an increasing burden of mental disorders,
and a widening “treatment gap”.
04/10/2025 41
Why Study Psychiatry ?…
 About 25% of the world’s population will
develop mental illness at some stage in their
lives.
 Most of these live in developing countries
 In developing countries, most individuals with
severe mental disorders are left to cope with
their illness on their own.
 Around 20% of all patients seen at PHC have
one or more mental disorders.
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 Mental Health Problems in Ethiopia
Mental Health Problems Percent prevalence
Common mental disorders 12--17%
Schizophrenia 0.6--0.7%
Mood disorders 3.8--5%
Childhood disorders 12--24%
Substance dependence 4.0%
Problem drinking 2.7--3.7%
Khat abuse 22-64%
Suicide attempt 0.9-3.2%
Completed suicide 7.7/100,000/year
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Access to Mental Health Care

 Individual awareness

 Availability of mental health infrastructure

 Ability to recognize and treat

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Impact of Mental Disorders

 Mental and behavioral disorders have a large

impact on:
 Individuals
 Families and
 Communities

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 1. Suffering to the Patients
 Distressing symptoms of disorders
 Inability to participate in work and leisure
activities
 Worry about not being able to shoulder their
responsibilities towards family and friends
 Being fearful of becoming a burden for others
 Stigma and discrimination

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 2. Burden to the Families
 Providing physical and emotional support to the
mentally ill member
 Bearing the negative impact of stigma and
discrimination
 The stress of coping with disturbed behavior
 Disruption of household routine
 Restriction of social activities
 Expenses for the treatment of mental illness
 Prevent other members of the family from achieving
their full potential

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3. Cost to the Community

 The cost of providing care

 Lost productivity
 Some legal problems

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CASE MANAGEMENT

 Case management
 is a form of specialized psychiatric practice

 in order to treat people with severe mental

illness.
 Case management applies to people with long-
term difficulties in recovery:
 from psychotic disorders, such as schizophrenia, bipolar

disorder and schizoaffective disorder.

04/10/2025 49
 CASE MANAGEMENT, cont’d…
 Includes
 Working with patients (in community and
at their homes)
 Comprehensive assessment of patients’
health and social needs,
 Coordination of different services within
the mental health system and those from the
patient’s own natural environment,
 Placing the patient in the center of
attention in order to help him achieve his/her
own personal goals and
 04/10/2025
find their own personal way of recovery 50
CASE MANAGEMENT, cont’d…

 Case management includes:

 Assessment,
 Treatment according to the treatment
plan,
 Coordination of treatments and services,
when other services are used.

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CASE MANAGEMENT, cont’d…
 Case manager can be
 a professional from various
different fields
 associated with mental health
(well)
 treating the patient using his/her
professional skills and available
treatment services,
 depending on patient’s individual
needs.
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The goal of case management
 Facilitate access needed service
 Coordinate care for clients within the fragment
health care delivering system
 Provide care for avoidable episode illness among at
risk clients
 Control or reduce the cost of care accepted by the
client or third -party payers
 Case manager is responsible for negotiating with
multiple health care providers to obtain a variety of
service for the client

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 The goal of case management, Cont’d…

 Knowledge regarding the problem

 Client get:

▪ ability to solve problems

▪ improving work and socialization skill

▪ promoting leisure time and

▪ encouraging independence
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THE COMMUNITY AS CLIENT
PRIMARY PREVENTION

 Primary prevention within communities

encompasses:
1. Identifying stressful life events that precipitate
crisis and targeting the relevant population at high
risk
2. Intervening with these high risk population to
prevent or minimize harmful consequences.
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SECONDARY PREVENTION

 Secondary prevention is about early detection and

prompt intervention with individuals experiencing
mental illness symptoms.
 Adolescents could be hospitalized for a variety of
reasons including: conduct disorder, adjustment
disorder, eating disorder, depression, and anxiety
disorders.
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TERTIARY INTERVENTION

 Tertiary interventions are implemented after harm

to health.
 Therefore, they are reactive measures.
 The aim is to restore the mental health of the worker
to enable them to return to work.
 Some barriers identified:
▪ Public attitudes
▪ Fragmented system
▪ Poverty and race
▪ Private insurance
04/10/2025
▪ Public funding 57
Community mental health centers
(CMHC)
 The goal: to improve coping ability and prevent exacerbation
of acute symptoms.
▪ A major obstacle: lack of sponsorship
 Case management has become a recommended method of
treatment for individuals with a chronic mental illness.

04/10/2025 58
CMHC, cont’d…
 Bower(1992) has identified five core components and nursing role functions
that blend with the steps of the nursing process to form a frame work for
nursing case management.
 The core component include:
1. Interaction: relationship
2. Assessment: to settle Dx
3. Planning: agreement on goal of Rx
4. Implementation: delivering service
5. Evaluation: evaluates the client’s responses

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Mental illness and homelessness
 150 million people
 Although there is no exact count for the number
of homeless people across the globe,
 the World Economic Forum estimated that at
least 150 million people were homeless around
the world in 2021.
 2% of the world's population is homeless
 Deinstitutionalization movement is blamed to be the cause for
the increasing number of homeless population.

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Types of mental illness among homeless
person's.
 Schizophrenia

 Bipolar affective disorder

 Substance abuse and dependence

 Depressive disorder

 Personality disorders, and

 Organic mental disorders

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Components of Community Mental Health

1. Psychiatric service in long term care

2. Psychiatric emergency care
3. Day treatment/partial hospitalization
4. Residential programs
5. Psychiatric home care
6. Rehab and aftercare in mental health center

04/10/2025 62
Components of Community Mental
Health, cont’d…

1. Residential treatment program

 Sometimes called REHAB

 The “last-ditch“ approach to treat abnormal psychology and

psychopathology.

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 Residential Rx program…

Effective residential treatment programs provide:

1. A comprehensive evaluation clients
2. Clients’-centered treatment plan
3. Individual and group therapy
4. Care for child and adolescents
5. Nonviolent approach for youth

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Residential Rx program…

 Residential levels of care applies to all age groups of all

mental illness
 Psychiatrist should visit at least once per week

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Admission criteria

A. A DSM 5 diagnosis criteria

B. Risky behavior
C. Deterioration of his/her condition
D. Many tried and unsuccessful treatment

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Discharge criteria (Meet a or b, and c and d):
A. The consumer has met his/her individualized
discharge criteria.
B. The consumer has not realized substantial benefit from
Residential Treatment Services despite documented
persistent efforts to engage the consumer.
C. The consumer can be safely treated at a less
intensive or restrictive level of care
D. An individualized discharge plan with linkage to
appropriate, realistic and timely follow-up care is in
place.

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2. Rehab and aftercare in mental health
center
 The advent of atypical antipsychotics helped control
symptoms and make patients candidate for
rehabilitation
 Once the acute symptoms are under control,
rehabilitation should begin immediately.
 The rehabilitation needs of patients must be
individually assessed within the context of what they
wish to do with their life

04/10/2025 68
Rehab and aftercare in mental health center,…

 Can be in patient, outpatient or in CMHCs.

 Most evidence-based rehabilitative services are for individuals
with severe mental illnesses.
 Rehabilitation services are an integral part of inpatient care.
 Rehabilitation begins with an individualized care plans
 Rehabilitation must be multimodal in nature.

04/10/2025 69
Objectives of rehabilitation services

 To enable patients to achieve their optimal functioning

 To enable patients to live independently
 To empower patients to understand and manage their illness
effectively
 To encourage involvement of families in care

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Components of rehabilitation:

a) Formulation of individual care plans

 Bio-psycho-social management
 Multimodal service

b) Psycho-education
 Psycho-education includes didactic lectures
 Giving information
c) Family intervention
 Information for the family regarding the illness
 Include families with previous problem

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 Components of rehabilitation…
d) Social skills training and/or illness management
programmers
 This consists of practicing specific skills such as self care,
conversation, making friends etc.
e) Cognitive remediation
 This is based on 3 principles i.e.
▪ teaching new information processing strategies,
▪ individualizing treatment and
▪ helping to transfer this improvement in real life.

f) Job placement (supported employment)

 Searching a job
04/10/2025 72
Generally rehabilitation Components:

a) Psycho education
b) Family intervention
c) Activities of daily living
d) Management of daily routine
e) Grooming and personal hygiene
f) Job search and job matching
g) Effective use of leisure time
h) Illness management
i) Occupational therapy
j) Group therapy
k) Individual therapy

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 THANK YOU

04/10/2025 74