WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care

In 2008 the WPA General Assembly approved the Action Plan of the Association for the triennium of the Presidency of Professor Mario Maj. One of the items of the Plan is the production of guidelines on practical issues of interest to psychiatrists worldwide (1,2. The present document, providing guidance on lessons learned and mistakes to avoid in the implementation of community mental health care, is part of that project. In subsequent publications we shall describe in more detail the particular challenges and solutions identified in the various regions worldwide. Mental health problems are common, with over 25% of people worldwide developing one or more mental disorders at some point in their life 3. They make an important contribution to the global burden of disease, as measured by disability-adjusted life years (DALYs). In 2004, neuropsychiatric disorders accounted for 13.1% of all DALYs worldwide, with unipolar depressive disorder alone contributing 4.3% towards total DALYs. In addition, 2.1% of total deaths worldwide were directly attributed to neuropsychiatric disorders. Suicide contributed a further 1.4% towards all deaths, with 86% of all suicides being committed in low- and middle-income countries (LAMICs) each year 4. A systematic review of psychological autopsy studies reported a median prevalence of mental disorder in suicide completers of 91% 5. Life expectancy is lower in people with mental health problems than in those without (in some countries dramatically so) also due to their higher levels of physical illnesses 6. Mental health problems, therefore, place a substantial burden on individuals and their families worldwide, both in terms of diminished quality of life and reduced life expectancy. The provision of high-quality mental health care is vital in reducing some of this burden 7. In this context, the aim of this report is to present guidance on the steps, obstacles and mistakes to be avoided in the implementation of community mental health care, and to make realistic and achievable recommendations for the development and implementation of community-oriented mental health care worldwide over the next ten years. It is intended that this guidance will be of practical use to psychiatrists and other mental health and public health practitioners at all levels, including policy makers, commissioners, funders, non-governmental organizations (NGOs), service users and carers. Although a global approach has been taken, the focus is mainly upon LAMICs, as this is where challenges are most pronounced. There are wide inconsistencies between, and even within, countries in how community-oriented care is defined and interpreted. Historically speaking, in the more economically developed countries, mental health service provision has been divided into three periods 8: • The rise of the asylum (from around 1880 to 1955), which was defined by the construction of large asylums that were far removed from the populations they served. • The decline of the asylum or “deinstitutionalization” (after around 1955), characterized by a rise in community-based mental health services that were closer to the populations they served. • The reform of mental health services according to an evidence-based approach, balancing and integrating elements of both community and hospital services 8–10. Within a “balanced care model”, most services are provided in community settings close to the populations served, with hospital stays being reduced as far as possible, and usually located in acute wards in general hospitals 11. Differing priorities apply to low, medium and high resource settings: • In low-resource settings, the focus is on establishing and improving the capacity of primary health care facilities to deliver mental health care, with limited specialist back-up. Most mental health assessment and treatment occurs, if at all, in primary health care settings or in relation to traditional/religious healers. For example, in Ethiopia, most care is provided within the family/close community of neighbours and relatives: only 33% of people with persistent major depressive disorder reach either primary health care or traditional healers 12,13. • In medium-resource settings, in addition to primary care mental health services, an extra layer of general adult mental health services can be developed as resources allow, in five categories: outpatient/ambulatory clinics; community mental health teams; acute inpatient services; community-based residential care; and work, occupation and rehabilitation services. • In high-resource countries, in addition to the above-mentioned services, more specialized ones dedicated to specific patient groups and goals may be affordable in the same five categories described for medium-resource settings. These may include, for instance, specialized outpatient and ambulatory clinics, assertive community treatment teams, intensive case management, early intervention teams, crisis resolution teams, crisis housing, community residential care, acute day hospitals, day hospitals, non-medical day centres, recovery/employment/rehabilitation services. It is this balanced care model approach that has been taken here in considering community-oriented care. In low-resource settings, community-oriented care will be characterized by: • A focus on population and public health needs. • Case finding and detection in the community. • Locally accessible services (i.e., accessible in less than half a day). • Community participation and decision-making in the planning and provision of mental health care systems. • Self-help and service user empowerment for individuals and families. • Mutual assistance and/or peer support of service users. • Initial treatment by primary care and/or community staff. • Stepped care options for referral to specialist staff and/or hospital beds if necessary. • Back-up supervision and support from specialist mental health services. • Interfaces with NGOs (for instance in relation to rehabilitation). • Networks at each level, including between different services, the community, and traditional and/or religious healers. Community-oriented care, therefore, draws on a wide range of practitioners, providers, care and support systems (both professional and non-professional), though particular components may play a larger or lesser role in different settings depending on the local context and the available resources, especially trained staff. Underpinning the successful implementation of community-oriented mental health care is a set of principles that relate on the one hand to the value of community and on the other to the importance of self-determination and the rights of people with mental illness as persons and citizens 14,15. Community mental health services emphasize the importance of treating and enabling people to live in the community in a way that maintains their connection with their families, friends, work and community. In this process it acknowledges and supports the person's goals and strengths to further his/her recovery in his/her own community 16. A fundamental principle supporting these values is the notion of people having equitable access to services in their own locality in the “least restrictive environment”. While recognizing the fact that some people are significantly impaired by their illness, a community mental health service seeks to foster the service user's self-determination and his/her participation in processes involving decisions related to his/her treatment. Given the importance of families in providing support and key relationships, their participation (with the permission of the service user) in the processes of assessment, treatment planning and follow-up is also a key value in a community model of service delivery. Various conventions identify and aim to protect the rights of service users as persons and citizens, including the recently ratified United Nations (UN) Convention on the Rights of Persons with Disability (UNCRPD) 17 and more specific charters such as the UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Care adopted in 1991 18. The above-mentioned and other international, regional and national documents specify the right of the person to be treated without discrimination and on the same basis as other persons; the presumption of legal capacity unless incapacity can be clearly proven; and the need to involve persons with disabilities in policy and service development and in decision-making which directly affects them 18. This report has been written to explicitly align with the requirements of the UNCRPD and associated treaties and conventions. This guidance has been produced by taking into account the key ethical principles, the relevant evidence, and the combined experience of the authors and their collaborators. In relation to the available evidence, systematic literature searches were undertaken to identify peer-reviewed and grey literature concerning the structure, functioning and effectiveness of community mental health services or obstacles to their implementation. These literature searches were organized for most of the World Health Organization (WHO) Regions, reflecting the context of the report's main authors. There are limitations to this approach, in particular the WHO Eastern Mediterranean Region was not fully represented, and this report focuses upon adult mental health services. Accordingly, this guidance does not address the service needs of people with dementia or intellectual impairment, and of children with mental disorders. Searches varied according to local expertise and resources. Medline was searched for every region. Other databases searched were EMBASE, PsycINFO, LILACS, SciELO, Web of Knowledge (ISI), WorldCat Dissertations and Theses (OCLC) and OpenSigle. Searches, adapted for each database, were for M.E.S.H. terms and text words relating to community mental health services and severe mental illness. Other electronic, non-indexed sources, such as the WHO, Pan American Health Organization (PAHO), WPA, other mental health associations, and country-specific Ministry of Health websites, were also searched. Google was searched for PDFs published in European and African countries which contained the words “community mental health”. Searches were limited to articles published in the languages spoken by the authors covering each WHO Region, and authors sought relevant advice from WHO Regional Advisors. Electronic searches were supplemented by searches of the reference lists of all selected articles. Hand searches of issues from the past five years of three key journals relevant to Africa (African Journal of Psychiatry, South African Journal of Psychiatry, and International Psychiatry) were also conducted. In addition, key texts were identified: these included relevant papers and book chapters published by authors of the current work 19–24 and a special edition of the Lancet on Global Mental Health 25–29. WHO publications which provide information regarding community mental health services worldwide were also sourced 7,31–33. 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