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DELHI PSYCHIATRY JOURNAL Vol. 13 No.

1 APRIL 2010

Review Article
Integration of Mental Health in Community
setting with Psychiatry for person concept
R.C. Jiloha, Lokesh Singh Shekhawat
Department of Psychiatry, Maulana Azad, Medical College & GB Pant Hospital, New Delhi

Organization of mental health services has work and therefore improve the accessibility of
remained a subject matter of many seminars and services. Furthermore, people who receive such
workshops. The essential focus of these scientific services indicate their preference for community
meets has been on the discrepancy between the over hospital-based care 7,8. Therefore, primary care
enormity of mental health problem and available is one of the prime portals for the care of the
technical know-how in the country. Majority of the mentally ill. It holds a myriad of opportunities for
patients suffering from mental disorders do not mentally ill ranging from health promotion to
receive treatment and needlessly suffer from disease prevention and treatment 9. Community care
distress and disability. Mental disorders are highly is better preferred because
disabling ranking second only to cardiovascular (i) It is a first point of patient contact with the
conditions as a leading cause of worldwide health care system, primary care is often
disability 1. These disorders impose substantial cost closer to home or workplace.
burden to patients, their families, and communities (ii) It is more affordable than the specialty care.
at large. That burden is reflected in lost productivity (iii) It offers cost-effective treatment
and expenditure on specialized treatment. (iv) It has potential for early identification of
For many years, people with mental disorders symptoms.
have been removed from their communities and kept (v) It provides for co-ordination and continuity
in psychiatric hospitals or institutions. There is a of care for both mental and somatic
great deal of evidence from around the world that disorders.
these institutions lead to further stigmatization of (vi) Primary care taps family as a source of
patients, are often associated with human rights support.
abuses, and in many cases lead to fur ther (vii) It is less stigmatizing than the specialty
deterioration in mental health of the inmates 2. A care.
definite need for a new care environment – away Over the past many years, experience with
from the conventional long-term hospital model to community mental health and integration of mental
a more community and mobile care-centred model health with primary health care has provided an
was felt. In response to this need, community based opportunity to work within an established
mental health services were initiated. There is good partnership with patients over time (continuity of
evidence to show that these community mental care), and as a consequence encounter over time
health services are both more clinically effective 3,4 various illness and diseases in the same individual.
and more cost-effective 5,6. They provide an ethical Now, it is evident that patients’, families’ and carers’
basis for care that respects the rights of people with priorities are different in every country and in every
mental disorders. They also allow for the delivery disease area and every individual is unique in his
of care near to the places where people live and or her own way of experiencing and coping with

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APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1

health problems within their specific life circum- and championed by patient/user groups and likely
stances and clinicians have to be able to handle that minded clinicians, is the recovery movement 10 ,
diversity. On these bases, an expansion of the focus which attempts to go beyond symptoms removal
of medicine from disease to patient appears and functional improvement to promote a
compelling. In the global context issues of access flourishing of the whole person and quality of life.
to treatment, patient safety, patient involvement in Mental health is a person’s ability to function
health policy, health communication and and to be productive in life; to adapt to changes in
information are vital to this sort of healthcare his/her environment, to cope with adversity and to
system. It has also been seen that this approach not develop positive relationship.
only important to relieve the patient’s anxiety but The practice of person-centered medical care
also to improve the provider’s job satisfaction3. The requires physicians to examine basic questions
response to a health problem is more likely to be about the scope of medical responsibility, the nature
effective if the provider understands its various of the therapeutic doctor-patient relationship, and
dimensions4. For a start, simply asking patients how the types of procedures that are appropriate in
they feel about their illness, how it affects their lives, treatment and health promotion. Once well-being
rather than focusing only on the disease, results in is recognized as an integral part of health care, then
measurably increased trust and compliance5 that health promotion must address the whole art and
allows patient and provider to find a common science of living well. Human beings only flourish
ground on clinical management, and facilitates the when they are self-directed, cooperative, and self-
integration of prevention and health promotion in transcendent13. Each human being has an intrinsic
the therapeutic response 3,4 . Thus, per son- dignity as a result of their capacity for self-
centredness becomes the “clinical method of awareness and self-actualization. Consequently the
participatory democracy”6, measurably improving person-centered physician becomes a consultant
the quality of care particularly in the industrial and adviser to assist people in their quest to live
world 4, the success of treatment and the quality of well.
life of those benefiting from such care: improved There are five principles essential for person-
treatment intensity and quality of life 7 better centred healthcare, which resonate with patients’
understanding of the psychological aspects of a organizations globally:
patient’s problems,8,9 improved patient confidence (i) Respect for individuals’ unique preferences
regarding sensitive problems10; increased trust and and needs;
treatment compliance 5 ; better integration of (ii) Choice and empowerment;
preventive and promotive care3. (iii) Patient involvement in health policy;
(iv) Access and support; and
What is ‘Psychiatry for Person’ Concept?
(v) Information that is accurate and presented
So far, the health care focuses only on the in an appropriate way.
disease and neglects the real people According to The practice of medicine for person needs
the concept of person-centred psychiatry, the whole practical and effective approach that includes,
person of the patient is the centre and goal of clinical (i) Understanding the personality of the
care and health promotion11. Historically, Chinese individuals including their emotional style,
and Ayurvedic medical traditions encourage a broad their goals and values, their strengths and
concept of health and a highly personalized weaknesses physically, mentally, socially,
approach to care and health promotion. Ancient and spiritually.
Greek philosopher, Socrates emphasized that if (ii) There must be a therapeutic alliance in the
whole is not well, it is impossible for the part to be sense of a relationship of mutual trust and
well12. Currently there has been a renewed assertion respect in which the physician and patient
that there is no health without mental health. The agree to work together toward common
focus has been on totality of the person. Converging goals.
with the above there are a number of recent clinical (iii) Physicians need to communicate in a
developments. Starting in the rehabilitation field reassuring and hopeful manner.
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DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010

(iv) Once a person is calm, they can face and context, needs, values, life projects and
accept unpleasant facts, such as information illness experiences.
about a possible disease or abnormal test (ii) Value and Need for Comprehensive
results. Diagnosis care and integration of services
(v) It is empowering for a person to take to achieve a person centred psychiatry and
responsibility and act in ways that are medicine. It includes: (a) histor ical
purposeful and resourceful to improve their perspectives; (b) philosophy of science
lifestyle to promote health. perspectives; (c) ethics and values
Person-centred care has also been applicable perspectives; (d) biological perspectives;
in developing world as part of the characteristics (e) psychological perspectives; (f) socio-
of “good” quality of care as well as its measure- cultural perspectives; (g) perspectives from
ment14 . health stakeholders.
World Psychiatric Association’s Initiative on Clinical Diagnosis Component
Psychiatry for the Person There are two work objectives in clinical
In the light of historical perspectives and recent diagnosis component17-19
developments, the WPA’s General Assembly (2005) (i) Development of ICD Classification20,21
established an Institutional Program of Psychiatry (ii) Development of Person-centred Integrative
for the Person (IPPP) proposes the whole person in diagnosis (PID) 22-24 which includes
context as the center and goal of clinical care and — positive and negative aspects of health
public health. This involves the articulation of within the person’s life context.
science and humanism to optimize attention to the — health related problems
ill and positive health aspects of the person. IPPP — positive aspects of health such as
aims at promoting a psychiatry of the person (of adaptive functioning, protective
his/her whole health, covering both ill and positive factors, and quality of life.
aspects), a psychiatry by the person (with — attending to the totality of the person
psychiatrists and health professionals extending including dignity, values, aspirations…
themselves as total human beings and not merely
Clinical Care Component
as healing technicians), a psychiatry for the person
(promoting the fulfillment of the person’s health Currently the focus of attention is just illness
aspirations and life project and not merely disease with minimal attention to positive aspects of health
management), and a psychiatry with the person and its totality as well as the dignity of the person
(working respectfully and in an empowering manner cared for. This component involves the preparation
with the person who consults). This initiative of curricula for graduate, post-graduate, CME and
represents a conceptual shift in psychiatry and training level in both specialty and primary care
potentially in medicine at large. It is already level. The curricula will promote the development
attracting wide attention throughout WPA and other of knowledge, skills and attitude relevant to person
major international medical and health centred psychiatry and cultivation of clinician-
organizations15. The IPPP has four components, i.e., patient relationship.
conceptual bases, clinical diagnosis, clinical care, Public Health Component
and public health.
The public health component includes
Conceptual Component development of policies and service. It also includes
There are two central concepts16 research and evaluation to support them
(i) Broad Notion of Health, which includes ill incorporating the values and dignity of the person.
and pathological aspects, positive aspects Failure to recognize the humanity and dignity
such as adaptive functioning, protective of the mentally ill and value of mental health to
factors, and quality of life and the notions individual and community leads to abuse and
of the person such as autonomy, history, neglect of mentally ill and loss of opportunities to

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APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1

improve mental health through population-based Training and Practice Guidelines


initiative. The public health component will foster To implement the programme there is no
research and evaluation of ill and positive health sufficient supply of well trained mental health
and consider the totality of person in the society. professionals in rural areas and many other parts
This will include: of the country26. There are few training programmes
(i) Design of public policy to promote popula- and practically no practice guidelines that
tion health emphasize the integration of mental health services
(ii) Develop monitoring of person and and primary care.
community-oriented health services in a • Primary care providers generally have little
culturally appropriate manner and policy formal training in the diagnosis and
and service development for mental health treatment of mental disorders and even less
promotion and mental illness prevention. in promoting mental health wellness and
Major obstacles in the path of integration of disease prevention.
mental health in community settings with • Primary care providers have sparse
psychiatry for person concept guidance about decision support i.e. what
disorder (alone or in combination) and at
In Indian context operationalization of
what level of severity can be treated
community mental health and integration of mental
effectively in primary care versus being
health with person centred psychiatry is likely to
referred to specialty care.
face several problems:
• There are no incentives for the educational
(i) Limited trained manpower
institutions and professional organizations
(ii) Uneven distribution of existing manpower
to step beyond existing training and
(iii) Low priority with corresponding low
practice programmes to embrace integrated
budget for mental health
and collaborative approaches.
(iv) Primary care physicians are not comfor-
table with managing persons with mental Recommendations Toward Core Principles to
illness provide a Frame-work:
(v) Lack of awareness about the medical nature (i) Emphasis on Consumers and their
of mental illness in the community Families: Cultural and ethical diversity
(vi) Poor access to care (travel time, convenient should be respected
availability of services Poverty (ii) Promoting Health and Overcoming
(viii) Poor availability of medications Disparities:
(ix) People preferring to go to faith healers, (iii) Basic Characteristics: Research, training
religious healers or traditional healers. and practice should incorporate consumer,
All these problems will not only be family and professional partnership; cross-
continuously faced at the time of integration of this disciplinary professional collaboration;
concept it will also face few other difficulties like25: population-based health-care; a holistic
(i) Unavailability of trained clinicians of this approach to health-care; and respect for and
concept understanding the role of spirituality and
(ii) Lack of proper preparation at this stage that traditional healing practices.
will be further compounded by cross- (iv) Financial Incentives for team approach to
cultural conflicts, social stratification, care.
discrimination and stigma. (v) Collaboration: Integrated service delivery
(iii) Conflicts of interest between provider and should be guided by commitment to
patient, particularly in unregulated collaboration of services.
commercial settings, are a major disincen- (vi) Continuity of Care: There should be
tive to person-centred care. treatment of chronic illnesses and
continuity of care.
(vii) Standardized Quality and Outcome
Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society 15
DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010

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