Some Aspects of Community Psychiatry

The purpose of this paper is to describe some aspects of community psychiatry in relation to a community psychiatric project in a geographically delimited area in Denmark. Leighton and Longaker (1957) described some aspects of the psychiatric clinic as a community innovation from the experience gained in the Bristol psychiatric clinic in Stirling County where approxi mately 2 per cent, of the 20,000 inhabitants were seen as patients in the clinic or in their homes during the first 5 years of the project. The experience gained in the Stirling County study has been further discussed in later publications (Leighton, 1959; Hughes, Tremblay, Rapaport, and Leighton, 1960). Carse, Panton, and Watt (1958) described community psychiatry in the Worthing area with a population of 160,000, where all patients with mental illness referred by general practitioners are seen by psy chiatrists before the decision about admission to a mental hospital is made. During the first 10 months of this service, 1,192 patients were referred and 1,000 domiciliary visits were paid to 432 of them. The admission rate fell by 40 per cent, during this period, because of the many instances in which the psy chiatrist concluded that admission to a mental hospital was not necessary. More than half the time of the consultants at the Mapperly hospital is spent in extramural activities in the Nottingham community psychiatric services (Macmillan, 1956, 1958a, b, 1963). Macmillan re gards domiciliary visits to psychiatric patients as extremely important and in many respects superior to the use of out-patient clinics. He mentions that a community mental health scheme makes it possible to see almost all patients referred to psychiatric institutions at home and to decide upon the appro priate in-patient unit before admission. He stresses the importance of liaison with the general prac titioners, saying that in the future we shall talk less about the number of beds in the hospital and more about the size of the community it serves. In planning for the future, according to Macmillan, a population of 250,000-300,000 would seem to be the maximum for a mental health service. Querido (1954) and Millar and Henderson (1956) described the com munity mental health service in Amsterdam where extensive use of domiciliary service is made. Sains bury and Grad (1962) and Grad and Sainsbury (1963) have made comparative studies of the burden on the family and the results of treatment in the hospital-centred conservative psychiatric treat ment service in Salisbury and the community psychiatric service in Chichester. Introduction of the community service in Chichester caused an average fall in admission of 43 per cent. (55 per cent, from within 10 miles of the hospital and 14 per cent, from more distant areas). The overall relief for the patients' families was greater in the hospital-centred service, but families whose burden was heavy were equally relieved in both. Although the admission rate was twice as high in the hospital-centred service, relief was not more closely related to admission in one service than in the other. Analysis of the clinical features of the patients and of the social character istics of their families indicated that relief to families in a community-care service can approach relief in a hospital-centred service. May, Sheldon, and Mac Keith (1962), in a report of the future of district psychi atry, describe the attempt of the Croydon psychiatric service to change hospital-oriented psychiatry to a comprehensive system of district psychiatry. They mention that general practitioners play a crucial part in the district psychiatric service and stress that home visits with support and advice to family, relatives, and others in the immediate environment are of great importance in treatment. May and Moore (1963) describe the value of the mental nurse in community psychiatry, especially in the treatment of geriatric patients. Domiciliary visits are used in a psychiatric clinic established by the Oslo Helserad 85