mental health nursing

3. Outline
• Mental Health
• Community Mental Health
• Community Mental Health Nursing
• Community Mental Health Program (CMHP)
• Aims of CMHP
• Elements of CMHP
• Strategies Adopted in CMHP
• Services Rendered Under CMHP
• Welfare Agencies in CMHP
• Role of CMHP in Disaster Management
• Limitation of CMHP

4. Cont.....
• APD’s community Mental Health Program
• Raipur Rani Project
• The Barwari Project
• Ranchi Institute of Neuropsychiatry and Allied sciences Experience
• The Bellary Project
• A Community Mental Health Programme in Rural Tamil Naidu
• Sakalawara Community Mental Health Centre

5. Mental Health
• “Mental Health is a state of well-being in which an individual realizes his or her own
abilities, can cope with the normal stressors of the life, can work productively, and is able
to make a contribution to his or her community.”
• Mental Health includes our emotional, psychological, and social well-being. It affects how
we think, feel, and act. It also helps determine how we handle stress, relate to others, and
life make choices.

6. • Biological factors, such as genes or brain chemistry
• Life experiences, such as trauma or abuse
• Family history of mental health problems
• School and adolescent Period
Factors contribute to Mental Health
Problems

7. Community Mental Health
• Community Mental Health is the
application of specialized knowledge to
population and communities to
promote and maintain mental health,
and to rehabilitate population at risk
that continue to have residual effects of
mental illness.

8. • Community mental health care is comprising the principles and practices needed to
promote mental health for a local population by:
a) addressing population needs in ways that are accessible and acceptable
b) building on the goals and strengths of people who experience mental illnesses.
c) promoting a wide network of supports, services and resources of adequate capacity.
d) emphasizing services that are both evidence‐based and recovery‐oriented.
Cont.....

9. Community Mental Health Nursing
• Community Mental Health Nursing is the application of knowledge of psychiatric
nursing in promoting and maintaining mental health of people, to help in early
diagnosis and care and to rehabilitate the clients after mental illness.
• Psychiatric nurse must possess knowledge about community resources.

10. Cont.....
• Community Mental Health nursing is a field that is a blend of primary health
care and nursing practice with public health nursing.
• The Community nurse conducts a continuing and comprehensive practice
that is preventive, curative and rehabilitative.
• The philosophy of care is based on the belief that care directed towards the
individual, the family and the group contributes to the health care of the
population as a whole.

11. Goal’s
• Provide prevention activities to population for the purpose of promoting
mental health.
• Provide prompt interventions
• Provide corrective learning experiences
• Help individuals develop a sense of self worth and independence.
• Anticipate emotional problems
• Identify and change social and psychological factors that influence human
interactions
• Develop innovative approach to primary preventive activities
• Provide mental health education and how to assess the mental health.

12. Preventive aspects of Mental Health
 Primary Prevention
 Secondary Prevention
 Tertiary Prevention

13. Primary Prevention
Primary prevention seeks to prevent
the occurrence of mental disorders by
strengthening individual, family and
group coping abilities.

14. Nurse’s Role in Primary Prevention
• Individual centered interventions
• Interventions oriented to child in school
• Family centered intervention to keep families intact
• Interventions for families in crises
• Community health education
• Society centered preventive measures

15. 1. Individual Centred Interventions
Antenatal care to the mother and educating her
regarding the adverse effects of radiation, certain
drugs and prematurity.
• Advise her not to be tense
• Develop positive attitude towards expected baby
• Emphasize on importance of balanced diet

16. 2. Well planned obstetrical care during natal
period
• Plan for delivery, prefer institutional care
• Take decision for LSCS timely
• Care of new born especially in cases of
forcep delivery, prolonged labor, NNJ, Birth
Asphyxia, congenital anomalies like-cleft lip
& palate, T.E.Fistula etc.

17. 3. Post Natal Management
• Psychological Care of mother especially
those who are anxious, worried or not
satisfied with the outcome to prevent
possibility of post partum depression.
• Timely vaccination of under five babies.
• Exclusively breast feeding up to 6 months.
• Adequate love and affection to child to
make him physically and mentally healthy
• Be watchful to assess developmental
delays-like –delay in speaking, delay in neck
holding, delay in standing & walking.

18. 4. Care of Elderly People
• Listen to them
• Identify their needs physical and mental and plan
accordingly
• Assess support system available to them
• Utilize their usefulness to society like-teaching skills,
social relationship etc.

19. 5. Identify population experiencing situational
crisis
• Like- failure in exam or business,
unemployment, marital conflict, divorced,
death of loved one or bread earner of
family, drug addicts, rape victims.
• Plan counseling services for these
people to assist them in coping the
situation and refer to psychiatrist if it is
needed.

20. Cont.....
• Detect cases of severe mental illnesses
and mental retardation.
• Telling family members about the
services available like- NGO’s working in
these areas, facilities available for MR
cases, special educational schools
available.
• Counseling services to needy population.

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

22. Mental Healh Services avaliable at the Primary
Level:
• SUB CENTRE
• PHC
• CMHC
Activities :
• First aid
• Nursing care of outpatients and inpatients
• Mental health education
• Identification of cases and referral in community
• Follow up

23. Secondary Prevention
• Secondary prevention targets people
who show early symptoms of mental
health disruption but regain premorbid
level of functioning through treatment.

24. Cont......
• Educate the public and prominent persons who
are in close touch with community like-PHN,
teachers, Religious leaders, retired persons etc.
in how to recognize early symptoms of mental
illness.
• Refer to Right Place at right time.
• Organize screening camps-Organize mental
health and psychiatric training to health
personnel- doctors, nurses, and social workers
etc. to increase human resources.

25. Cont.....
• Mental health education to public to
increase awareness
• Provide Health Education to newly
diagnose patients and their family
on drugs, side effects of drugs.
• Early detection and treatment of
preventable disorders.

26. Some interventions include:
• Early diagnosis and case finding
• Early reference
• Screening programs
• Early and effective treatment for patient
• Training of health personnel
• Consultation services
• Crisis intervention

27. Tertiary Prevention
• Tertiary prevention targets those
with mental illness and helps to
reduce the severity, discomfort and
disability associated with their
illness.

28. Nurse’s Role
• Help people to move to their previous level of health
• Rehabilitation of function adequately in the physical, mental, social, economic and
vocational areas of their lives.
• Outreach programs for mental health
• Involve family members
• Address the stigma issues & concealment
• Help cope with guilt and improve self-esteem
• Foster healthy attitudes

29. Introduction:
• The National Mental Health Survey reported the prevalence of psychiatric morbidity
in India as 10.6% .The survey also observed that about 150 million people are in
need of active psychiatric treatment and nearly 12 million people are living with
serious mental disorders in India.
• Community mental health services aim to treat people with mental disorders in their
homes or domiciliary settings, instead of a psychiatric hospital.

30. cont........
• Three factors served as inspirations for the community mental health movement in
India.:
• The first was the identification in Western countries that following long-term
hospitalization of psychiatric patients develop institutionalization or social
breakdown syndrome and had difficulty in reintegrating into the community.
• Second is the recognition that the cost of delivering psychiatric care by well-trained
doctors located in hospitals is prohibitive.
• The third was the discovery in other developing countries that para- and
nonprofessionals could be trained with innovative, short, and simple courses to
deliver reasonably adequate mental health care. This greatly reduces the cost of
delivery of mental health care.

31. cont.......
• Since independence various initiatives by the government has led to a significant
change in the place of mental health care as part of the general health care.
• At the time of independence apart from mental hospitals, there was practically no
organized mental health care. Since then General Hospital Psychiatry units and also
Psychiatric Nursing homes have started.
• The Bhore Committee Report of 1946, which laid the foundation for the community
health movement.

32. cont......
• Subsequently, the progress of health care in the country was reviewed by the
Srivastava Committee (1974). One of the recommendations of the committee was the
introduction of Community Health Volunteer (CHV) scheme. The plan was to train
one CHV for about 1000 population. Mental health was included in the training of
CHVs.
• Community Mental Health Care Programs imply that all mental health and well-
being needs of the community are met in the community, using community
resources.

33. Cont.....
• Formulation of National Mental Health Programme (NMHP); incorporation of
mental health care in primary health care (PHC) at the district levels; Supreme
Court judgments about mental hospitals and attempted suicide; Adoption of
Persons with Disabilities Act 1995 and the Mental Health Care Act 2017;
Initiatives of voluntary agencies in the areas of alcohol and drug dependence,
rehabilitation, and suicide prevention and wide media coverage of mental
health issues.
• The overall effect has been the movement to recognize mental health as an
important issue in the community and services to move beyond mental
hospital care to care to the community.

34. cont.......
• Two programs that have influenced the development of India's Community Mental
Health Program (CMHP) are the Raipur Rani Program and the Bellary District
Program.
• It goes much beyond only treatment and includes: Promotion of well-being and
mental health promotion, stigma removal, psychosocial support, rehabilitation of
those in need, prevention of harm from alcohol and substance use and treatment of
the ill using the PHC system.

35. Community Psychiatry in India
• Community psychiatry in India originated from the work of Dr. Vidya Sagar in
1950s, began to involve family members in the treatment of mentally ill patients who
were admitted to the Amritsar Mental Hospital.
• The relatives observed that patients with mental illness improved with treatment.
They also were taught about the basic principles of mental health care.
• The first general hospital psychiatric units (GHPU) began functioning in 1933 at the
R.G. Kar Medical College Calcutta, followed by one at JJ Hospital Bombay (1938),
Patna Medical College hospital (1939), and KEM hospital Bombay (1940). Army
Medical Corps also played a part with the establishment of GHPUs.

36. cont......
• As a result of the GHPUs, psychiatric treatment became easily accessible and
acceptable to the general population and reduced the social stigma.
• A large number of GHPUs have started functioning all over the country. Most of
them are 30–50 bed units. As of now, there are over 3,000 beds under this facility in
different parts of the country.
• Thereafter, advances in mental health services in India have shifted the emphasis to
the community care paradigm. The thrust for this approach came from the following
sources:

37. cont......
i. Obligation of the country to provide health services to all
ii. Availability of a large infrastructure of general health services (PHC system)
iii. The Alma Ata declaration of PHC
iv. The approach to utilize rural Doctors and Multipurpose Workers to provide health
care to rural people
v. Recognition of the amount of severe mental disorders in the community (at least 1%)
and availability of simple interventions for these conditions
vi. Experiences of community mental health care at Bangalore and Chandigarh centers.

38. Community Mental Health Programme:

39. Community Mental Health Programme:
• The Community Mental Health Programme includes all community facilities
pertinent in any way to prevention, treatment, and rehabilitation. –(K-Park)

40. Aims of Community Mental Health Program:
1. To ensure treatment and prevention of mental and neurological disorder.
2. Use of mental health technology
3. Application of mental health principles in total national development to improve
quality of life.

41. Elements of Community Mental Health Program:
 Inpatient services
 Outpatient services
 Partial hospitalization
 Emergency services
 Diagnostic services
 Education services
 Training
 Research and evaluation.

42. Services rendered under Community Mental
Health Program:
 Early diagnostic and treatment
 Rehabilitation
 Group and individual psychotherapy
 Mental health education
 Use of modern psychoactive drugs
 After-care services

43. Strategies adopted in Community Mental
Health Program:
 Integration of mental health with primary heath care through the national mental health
program
 Provision of tertiary care institutions for treatment of mental disorders
 Eradication stigmatization of mentally ill patients and protecting their rights through
regulatory institutions like the central mental health authority, and state mental health.

44. Therapeutic services provided by Community
Mental Health Centers
 Medication
 Individual and family therapy
 Crisis intervention
 Social skills training

45. Major functions of community health nurse in CMHP
 Assisting in the immediate diagnosis and treatment of mental illness.
 Making special arrangements to protect and take care of patients to prevent them, from
physical injuries and attempted suicide.
 Establishing the importance of mental health in general patients and telling them the
methods of attaining good mental health.
 Follow up of mental patients.

46.  Conducting guidance clinics.
 Assisting the patients in social rehabilitation after treatment
 Providing mental health education during home visits, hospital nursing and
community care.
Cont.......

47. Some interventions include:
• Family members should be involved actively in the treatment program so that
effective follow-up can be ensured.
• Community based programs can be launched through meeting with the family
members when the need for discharge from the hospital should be emphasized. These
programs can be implemented through day hospitals, night hospitals, after care
clinics, half-way homes, ex-patient hostels, foster care homes etc.

48. Cont..
• Another aspect of community life that is more difficult to assess accurately and deal with
effectively, is the stigma attached to mental illness.
• Many patients and their families try to avoid stigma by keeping the nature of the person's
illness a secret. The need for secrecy places additional stress on the family system because
there is always the fear that the truth will be revealed.
• Monitor community attitudes and help in fostering a realistic attitude towards the mentally
ill.

49. Limitations of Community Mental Health
Program:
 Non-availability of psychiatrists and other mental health professionals.
 Low level of community participation
 Inadequate funding for community mental health program
 Shortage of delegation of power for procuring medicines and recruiting staff
under the program at the community level.
 Lack of co-ordination between National mental heath department and
community level mental health department.

50. APD’s Community Mental Health
Programme

51. APD’s Community Mental Health
Programme
• In Karnataka, over 50 lakh people with mental illness (PWMI) and mental retardation
are supported by less than 700 healthcare professionals, doctors and social workers.
• Lack of awareness and limited access to mental health care coupled with social stigma
makes reaching out to people with mental illness a tougher task.

52. • In economically backward social groups, both urban and rural, people with mental
illness are subject to neglect, isolation, abuse and traditional forms of treatment – all of
which have a negative impact on them.
• APD’s Community Mental Health Program has been operational since 2004. The
program is active in 4-5 taluks of Davangere district.
Cont.......

53. Program Objective
• Social integration and economic rehabilitation of
people with mental illnesses while increasing
acceptance and knowledge about mental health
among communities.

54. APD’S Approach
• Awareness is critical in the Community Mental Health program. To reach people, APD
conducts many activities such as:
• Mental health training
• Mental health wall writing in key public places
• Street exhibitions in public places
• Stress and stress management training

55. School and College Awareness Program
• APD conducts stress management training to
support students suffering from stress
because of board exams, competition,
parents’ expectation, etc.
• The trainings are conducted by experts from
the field and trained personnel. Teachers are
also sensitized to the need of listening to the
students’ voice.
• Over 3,436 students have been sensitized
though the stress management training.

56. Residential Training Program for PWMI
• A residential training program of 4 days is
conducted for PWMI and caregivers in
Davangere district. The training involves:
• Team building activities
• Orientation on RPD Act, 2016; PWD Act,
1995; and The Mental Healthcare Act,
2017
• Sharing of case studies with parents and
other caregivers
• Awareness on local self-employment
• Discussion on career challenges

57. Raipur Rani Project
• The Chandigarh efforts to prepare a model for rural psychiatric services were
initiated in 1975, based on the observation that hospital-based psychiatric services
were inadequately utilized, especially by the rural population.
• The essential advance in this model was the incorporation of psychiatric care with
general medical care, thus providing basic mental health care at the doorstep.
• Based on the experience of providing mental health care through different methods
as well as the overall goals of health care in general, the government launched the
NMHP in 1982.
• One of the most important initiatives undertaken under the NMHP was the
integration of mental health with PHC at the district level.

58. Cont.......
• To implement the NMHP at district level NIMHANS launched a pilot project in the Bellary
district in 1985.
• Later, in 1996–1997, the DMHP was implemented in one district each in Andhra Pradesh,
Assam, Rajasthan, and Tamil Nadu. During the ninth 5-year plan, it was extended to 27
districts across 22 states/union territories.
• The NMHP was modified during the tenth 5-year plan with the expansion of DMHP to 110
districts.
• There was emphasis on execution of information, education, and communication activities
• The drawbacks of program were - low rates (20%–40%) of identification of psychiatric
disorders, poor training of staff, poor training, motivation and retention of staff, and over
burdened PHC doctors being allotted extra work.

59. GMCH, 32
• The department has always given highest priority to the community out-reach services since
its inception. The first community service was started in Gurudawara at Palsora village. After
that new villages were added.
• Currently department is providing community out-reach services at three places adjoining
Chandigarh viz Dhanas, Khuda Alisher and Hospital dispensary- sector-26.
• The community team which comprised of psychiatrist, resident doctor, clinical psychologist,
medical social worker and staff nurse examines patients at these places on weekly basis and
dispense medicines.
• The department also organizes 7 days indoor de-addiction camp annually in the villages of
Chandigarh with the help of local Panchyat after prior screening and identification of
patients. In addition to indoor camps, department is also holding one day OPD camps in the
community every month to enroll new patients with mental health issue and substance use
disorders.
• Schedule of Community Outreach Clinics (COCs) from 9.30AM-12.30PM

60. Cont...
• Tuesday- Dhanas
• Wednesday- Khuda Alisher
• Thursday- Police line clinic, sector 26
• In addition to above community outreach service, the community team also visits Burail Jail
and Pingalwara Ashram on alternate Friday.

61. State Resource Centre
• The office of SRC is presently located in the Department of Psychiatry. Regular monthly
camps are conducted under SRC in community for identification of persons with disability
and certificates are issued.
• Rehabilitation Services via NGOs Parivartan, Umeed and Prayatan :
• Vocational rehabilitation of the mentally challenged and mentally ill has been taken up by the
department in a very novel and unique way. A number of kiosks (snack huts/ juice bars) have
been set up in different locations across Chandigarh providing employment to such persons
under supervision of guardians of similarly disabled persons.

62. Cont....
• Government Rehabilitation Institute for Intellectual Disabilities (GRIID)
:www.griid.edu.in
• Teaching : Department has given a high priority for teaching undergraduate medical students.
Training is provided to Medical undergraduates as per MCI. It includes both theory lectures
and clinical classes

63. DISABILITY ASSESSMENT REHABILITATION &
TRIAGE (DART)/ MENTAL HEALTH INSTITUTE( MHI)
• Disability Assessment Rehabilitation and Triage (DART) service was started on 31st
December, 2012 for providing need based non pharmacological services for the patients of
chronic mental disorders who have recovered from acute phase of illness, but still have
significant deficit in social, cognitive and vocational skills. In Feb 2017 inpatient
rehabilitation services were started initially in the DART building but later on shifted to
Mental Health Institute (MHI). Currently the same has 40 beds for rehabilitation and these
are used as teaching beds by Department of Psychiatry.

64. Cont.....
DART/MHI is designed to have following service components:
• Neurocognitive Rehabilitation Clinic
• Social Skills Clinic
• Vocational Rehabilitation Clinic
• Day Care
• Occupational Health Services(OHS)

65. Ranchi Institute of Neuropsychiatry and Allied
Sciences Experience
• Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) is a tertiary care
teaching hospital and research institute situated in the outskirts of Ranchi.
• RINPAS started community outreach program in 1999.
• The program was started at Jonha and other nearby villages of Ranchi district. Team
from RINPAS used to visit these centers every week. Members used to make door
to door visit of every village, meet village leaders, and tried to convince family
members to come to the center.

66. Cont.......
• The objectives of starting these community outreach program are to provide
services in the rural areas, to study the efficacy of these services, to involve the
community in organization of services and provide free medicines to the needy
and poor patients.

67. The Bellary Project
• NIMHANS launched a Community Psychiatry program in 1976.
• The aim of the rural project was to create appropriate training programs for the
doctors and the multipurpose workers .
• This was carried out by identifying the mentally ill persons in their homes through
key informants and those attending the general health facilities, that the trained
personnel of the PHC could provide basic psychiatric care.
• The program officer in charge of the Bellary model spoke about the difficulties in
diagnosing psychiatric disorders, selecting suitable medication, and its dose as well
as managing adverse effects of medicines.
• There were also administrative problems such as the transfer of personnel who had
been trained, low motivation of staff, and the irregular supply of drugs.

68. A Community Mental Health Programme in
Rural Tamil Nadu
• Community mental health rehabilitation programme carried out in a rural area in
Tamil Nadu by the Schizophrenia Research Foundation (SCARF).
• SCARF is a non-governmental, non-profit organization in Madras, working for
people with chronic mental illness.
• The community mental health project is funded by a Canadian donor (IRDC) and is
carried out in Thiruporur.

69. Objective
• Primary objective was to operate a community mental health programme in the
defined catchment area
• Training of volunteer workers to detect and manage mental disorders, operating a
mental health service system in the area, planning and implementing an intervention
programme for the identified mentally ill.
• Integration of mental health with primary health care infrastructure in the area, and
conducting periodic awareness programmes in the community.

70. Sakalawara Community Mental Health Centre
[SCMHC]
• Sakalawara Community Mental Health Centre (SCMHC), NIMHANS has started
functioning from 1st March 2014
• Stable patients with chronic mental illnesses who need short-term rehabilitation
training and other psycho-social interventions can be referred to the team for
admission to the residential facilities

71. Services Available
• Behavioural Therapy
• Group Therapy
• Occupational Therapy
• Yoga
• Family Therapy
• Life Skills Training
• Social Skills Training
• Individual Therapy
• Activities of Daily Living

72. Cont.........
• Services provided in the clinic
• The services provided are step-down psychiatric care & psychosocial rehabilitation of
patients stable on medications for more than 4-6 weeks.
• The services include Daily Living Skills, Behavioural Work, Group Therapy, Occupational
Therapy, Family Therapy & Yoga carried out by a multi-disciplinary team of mental health
professionals.
• The services provided are also customized according to the individual need of the patient.

73. PGIMER
• The Department runs four community satellite clinics, located at the General Hospital
Naraingarh (Haryana), Community Health Centre Raipur Rani (Haryana), Civil Hospital
Kharar (Punjab), Primary Health Centre Boothgarh (Punjab) and a field community
psychiatry service in NandpurKallor (Punjab).
• Several community services, like School Mental health Services, preventive group session
for pregnant women, group session for people with alcohol or drug use disorders,
information-education-communication (IEC) activities in the community, are conducted in
the village Nandpur Kallor.

74. Summary
• Mental Health
• Community Mental Health
• Community Mental Health Nursing
• Community Mental Health Program (CMHP)
• Aims of CMHP
• Elements of CMHP
• Strategies Adopted in CMHP
• Services Rendered Under CMHP
• Welfare Agencies in CMHP
• Role of CMHP in Disaster Management
• Limitation of CMHP

75. cont.....
• APD’s community Mental Health Program
• Raipur Rani Project
• The Barwari Project
• Ranchi Institute of Neuropsychiatry and Allied sciences Experience
• The Bellary Project
• A Community Mental Health Programme in Rural Tamil Naidu
• Sakalawara Community Mental Health Centre

77. Conclusion
• Community mental health is the application of specialized knowledge to population
and communities to promote and maintain mental health, and to rehabilitate
population at risk that continue to have residual effects of mental illness.
• The community mental health program includes all community facilities pertinent in
any way to prevention, treatment, and rehabilitation.

78. References
1. https://www.apd-india.org/programs/disability-and-rehabilitation/community-mental-health
2. Giri DK, Chaudhury S, Chakraborty PK. Trends and issues in community mental health programs in
India: The Ranchi Institute of Neuropsychiatry and Allied Sciences experience. Ind Psychiatry J.
[Internet]. [cited 2021 Sep 4] Available from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836339/
3. R.Thara,R.Padmavathi.A COMMUNITY MENTAL HEALTH PROGRAMME IN RURAL
TAMILNADU.DINF.[Internet]. [cited 2021 Sep 5]. Available from:
https://www.dinf.ne.jp/doc/english/asia/resource/apdrj/z13jo0300/z13jo0310.html
4. Community Mental Health Program at APD India [Internet]. [cited 2021 Aug 28]. Available from:
https://www.apd-india.org/programs/disability-and-rehabilitation/community-mental-health.
5. K. Park. Park’s Textbook of Preventive and Social Medicine. 25th edition. Jabalpur. Bhanot. January
2019

79. Thank you