Community Psychiatry

Dr Pauline Larmour and Dr Isla Young

May 2023
 Community psychiatry
worldwide
 Meaning and provision vary according to resources &
culture
 Relatively modern development in psychiatric provision
 Advent of community psychiatry followed the discovery of
effective treatments for mental illness in the 1950s and
subsequent move away from traditional asylum-based
psychiatry in the UK and elsewhere
 Community Psychiatry in the UK/HIC
 Assessment
• Treatment:
Acute interventions

Early intervention

Rehabilitation

Long term care

• Provision of information and education about the condition

• Promotion of awareness re mental health
 Western community psychiatry
 Delivered by a multidisciplinary
team
 At a community clinic or
resource centre or patient’s own
home
 Community psychiatry in UK
Core team
 Nurses
 Psychiatrists
Working WITH the
 Social workers
Patient
 Support/]care workers
 Occupational Therapists
 Psychologists
 Admin and secretarial staff
 Community psychiatry in UK
The community psychiatric team also liaise with :
Patient’s family, carers, friends
Primary Care
Acute hospital staff
Social workers
Housing officers
Employment professionals
Other Supporters – e.g. pastor/priest/imam, patent advocate, neighbour
Police
Probation officers
Ambulance services
 What about Malawi?
 “In Malawi, mental health facilities are limited, services are
centralised and there are few mental health professionals.
 To increase access to mental health services, there is a need
to integrate services.
 Integration of mental health services in Malawi will
contribute to meeting the needs of those in poor and rural
areas by enabling access to mental health care.”

Michael Udedi 2016

 Medical Provision in Malawi
 WHO norm = 1 doctor for every 1000 people
 UK = 2.8 for every 1000 people
 Malawi = 1 doctor per 50 000 people

 UK – 1 psychiatrist per 12, 567 people

 Malawi – 3 psychiatrists for > 17 million people
Rather than
Community
PSYCHIATRY,
better to think in
terms of
COMMUNITY
MENTAL HEALTH
CARE
Community mental health care in
Malawi
 Western community mental health tends to be psychiatrist-
led
 Not realistic in Malawi.
 Importance of not trying to replicate Western mental
healthcare models in Malawi
 Instead - develop services and policies that build on and
maximise the effectiveness of resources and existing systems
of healthcare provision within Malawi
 Development of community
mental health services in Malawi
To better understand these, it is useful to look at how services have developed
historically
 In the beginning, worldwide:
 Mental illness not recognised
 Abnormal beliefs and behaviour seen as either criminal or
demonic
 Sufferers were dealt with
 by the family
 by the justice system –locked up in prison, fined or exiled,
at worst executed

 by religious systems – exorcised, exiled or punished

 History of mental healthcare provision in
Malawi
 1910 – at central prison, Zomba.
 prisoners who were clearly “abnormal” and disturbing staff
and other prisoners separated in a different wing of the
prison.
 known as the Zomba lunatic asylum but just a wing of the
prison - staffed by prison warders.
 Poor conditions - difficult cases locked in cells or put in
irons. No real treatment offered till the 1930s
 Mental healthcare provision in Malawi – early
20th Century
 health and education largely provided by missionaries but
they refused to admit “insane” patients
 most mental illness continued to be treated by traditional
healers
 They had effective remedies for neurotic illness but not for
psychoisis or epilepsy
 gradual recognition that insanity needed treatment just like a
medical illness and that mental health care was not best
provided by prison warders
Development of mental healthcare provision in
Malawi – 1950s
 1943 – annexe built to the asylum wing of Zomba prison
where ‘quieter’patients could live a less confined life and
grow their own food
 1953 – the ‘new’mental hospital was built and came under
the control of the medical department, rather than the prison
 1950s – effective antipsychotic drugs and ECT became
available, making it possible to treat serious mental illness
and return patients to the community
 development of mental healthcare provision in
Malawi – post 1950s
 Mental health services came to be associated with the
psychiatric hospital at Zomba
 At that time, the best thing to do with any mentally ill person
was thought to be to take them away and keep them safely
inside an institution until they were fit to return to the
community.

 What are the pros and cons of this approach?

 Historical limitations of asylum-based care
provided at Zomba psychiatric hospital
 80% Malawian population live in rural areas - Patients and
carers having to take time off work and travel to Zomba
 Patient taken away from family
 family and local community didn’t see them recovering
 fear of patient, difficulty being welcomed back
 Stigma of psychiatric hospital for patient’s future
 Cost of travel and institutional care V community
 Historical limitations of asylum-based care
provided at Zomba psychiatric hospital
 Patient became dependent on structured hospital regime and
struggled to readjust to normal life
 Over time, because care was only provided in the hospital,
the asylum became more and more overcrowded
 resulted in less time available for individual patients and
reduced quality of care
 Scope for dehumanisation and human rights abuses
 Difficulties providing follow-up
What attempts have been made
to address these challenges?
 Development of Community Mental Health
Care in Malawi – 1990s
 80% population living in rural areas
 Principals of bringing treatment, rehabilitation and mental
health promotion as near as possible to the patient and their
community
 Model proposed based on community healthcare models and
systems within Malawi that already existed for e.g. TB,
dental problems and orthopaedics
 Model was developed based on primary care workers,
specialist nurses and district hospital managers
 Proposals for Community Mental Health Care
in Malawi in the 1990s
 District Health Officers and teams to regularly visit all health
centres within a district, giving support to primary care
activities and provide immediate referral opportunities
 Psychiatrist and team from Zomba to regularly visit the
regions with the DHO and matron at each district hospital

 To support the psychiatric nurse, offer teaching sessions for

staff & seminars to general health workers to change
attitudes and encourage wider participation in care of
mentally ill
 Developing a Model of Community Mental
Health Care in Malawi
 Pilot project in Zomba district of psychatric nurses joining
the DHO team on health centre visits in the district.
 Rolled out to other areas
 Unfortunately, in practice, from the outset, regular psychiatry
visits to the local areas did not happen as planned
 Psychiatry and resources remained hospital-based &
concentrated in the main specialist tertiary facilities at
Zomba and Blantyre
 Current Organisation of mental health services
in Malawi
 28 administrative districts, each with hospital and community health
services

 Primary care - initial contact likely to be with a primary care worker in a

peripheral clinic

 Secondary care - Patient might then be referred to clinical officer or

psychiatric nurse at the district hospital

 Tertiary care - in the south - seriously ill cases may be admitted to

Zomba mental hospital or referred to Queen Elizabeth Hospital in
Blantyre for outpatient care

 Centrally and in the north, St John Of God run inpatient units in

Lilongwe & Mzuzu and small outreach clinic in Lilongwe for children
with a range of disabilities
 St John of God, Mzuzu
 OPD mental health services

 Community education

 Primary health care outreach clinics

 Rehabilitation and community re-integration

 Domiciliary care within the city of Mzuzu

 Community based rehabilitation for children with epilepsy and a

disability
 Livelihood enhancement for service users and their households

 Supported employment
 Benefits and challenges associated
with a community healthcare model
in Malawi
 Advantages of a Community Mental Health
Care Model in Malawi
 Person stays near their family - family can remain involved
in their care
 Family see them getting better and have the opportunity to
learn about mental illness
 Patients attending district general hospital – less stigma than
asylum-based care
 Triage - specialist ‘psychiatric’ inpatient and outpatient care
at the bigger centres reserved for more serious cases
 Model of Community Mental Health Care in
Malawi - advantages

 less costly for the health system

 don’t need to provide overtime for nursing staff, food and
clothing for inpatients
 cheaper for family as they don’t have to travel long distances
e.g some patients from Karonga, Rumphi are referred to
Zomba. Family have to travel over 600km to visit
 Challenges for mental health provision in
Malawi
 Resources – mental health funding remains a low priority &
at the bottom of the public health agenda
 Low salaries & poor working conditions for community
health workers leads to de-motivation and lack of
recruitment/retention/training/skills
 Consequently, expertise remains limited to the tertiary
centres
 Challenges for mental health provision
 limited and variable supply of and compliance with
psychiatric medications
 No treatment available for less severe conditions
 Staff delivering care in the communities need to be
incentivised, trained and receive ongoing support and
education

 Need for regular input and support from skilled senior

mental health staff
The Future of mental health services in Malawi
- ongoing challenges for patients
 In Malawi, treatment is free but patients may be unable to
afford the costs of travel and missing work
 Cyclical relationship between poverty and mental health -
mental health conditions reduces productivity and income –
poverty exacerbates/ increases risk of mental health
conditions
 Stigmatisation - beliefs re cause of mental illness still
alienates people with mental health conditions
 If unable to afford care, locked up and hidden from the
community ? – human rights violations?
 Stigmatisation
 In high income economies, diagnosis of mental illness can
carry stigma but can also entail sympathy and treatment from
established mental health services and support from the
welfare state
 In Malawi, destitution may await those with mental illness.
 Those in a state of poverty may be reluctant to consider that
they may be at risk of an even worse state
 Challenges to mental health care services
at Government level
 Mental disorders are the 4th most common cause of
disability in Malawi after HIV, cataracts and malaria.
 What priority is given to mental health ?

 Review of mental health act ?

 Development of a national mental health plan and mental
health policy ?
 Mental Health Policy
 Slow development of mental health services in Malawi has
been compounded by the absence of a mental health policy
 1st national mental health policy developed by 2001
 Provided for integration of mental health care into the
general health care delivery system but not fully
implemented by time it expired in 2005
 Malawi operating without a mental health plan or policy
since then.
 Mental Health Legislation
 Mental Health Act 1948
 Amended in the 1960s to deal with some forms of
discrimination
 Falls short of addressing some of the human rights issues
enshrined in the 1994 Constitution of Republic of Malawi
 Review of Mental Health Act started 2005 – not yet been
presented to Parliament?
Postive community mental health
developments and initiatives in
Malawi
 Local initiatives attempting to integrate community
physical and mental health
in Malawi

 Pilot project aiming to increase access to depression care by

integrating depression screening and management into HIV
care at primary health facilities
 Pilot programme that has attempted to integrate depression
care into hypertension and diabetes clinics
 Untapped resources in community mental health?
Local initiatives in Malawi
 Research project - Mental health facilitator training of lay
people in schools and communities in Malawi
 Research project - Clinical assistant training in Malawi
 Delivery of structured training shown to improve the quality
of detection and management of mental health needs in
communities throughout Sub-Saharan Africa
 Lots of time and effort spent on pilot and research
projects......
 Untapped resources in community mental health?
Approaches developed elsewhere in Southern Africa

 Friendship bench – system developed by psychiatry

professor in Zimbabwe
 Rolled out to a variety of countries in Africa and worldwide
 Training members of local communities to provide basic
support and CBT
 https://m.youtube.com/watch?v=GsumqfQm2Xc
 And some useful resource
materials for community mental
health in Malawi...
How do you think community
mental health services can be
improved in Malawi?
Zikomo!
 References – history of mental health
services in Malawi
 Malawi’s Mental Health Service, M G Wilkinson Malawi Medical
Journal, April 1992, vol 8, no 1

 A Historical Perspective of 50 Years of Mental Health Services in

Malawi, Genesis Chorwe-Sungani et al, The Society of Malawi Journal,
2015, vol 68 No. 2 (2015) pp31-38, vi

 Improving Access to Mental Health Services in Malawi, Michael Udedi,

Ministry of Health Policy Brief 2016

 The Progress on Mental Health Policy in East Africa, Liesl Hostetter,

Borgen Magazine, Global Health, September 1 2018
 References- reducing stigma
 Malawi. Felix Kauye & Chitsano Mafuta. International Psychiatry. Vol 4
number 1 January 2007

 Attitudes towards mental illness in Malawi:a cross-sectional survey. Jim

Crabb et al. 2012. BMC Public Health 12: article 541 (2012)

 Stigma of mental illness and ways of diminishing it. Byrne P. Adv

Psychiat Treat. 2000, 6:65-72.10.1192/apt.6.1.65

 Mental Health Facilitator (MHF) Service Implementation in Schools in

Malawi, Africa: A Strategy for Increasing Community Human Resources.
Melissa Luke et al, TPC journal March 24, 2016

 And some useful resources for community mental health in Malawi...

 References – pilot projects attempting to integrate
improvements in community physical and mental health in
Malawi
 Stockton MA, Minnick CE, Kulisewa K, Mphonda SM,
Hosseinipour MC, Gaynes BN, Maselko J, Pettifor AE, Go V,
Udedi M, Pence BW. A Mixed-Methods Process Evaluation:
Integrating Depression Treatment Into HIV Care in Malawi. Glob
Health Sci Pract. 2021 Sep 30;9(3):611-625. doi: 10.9745/GHSP-
D-20-00607. PMID: 34593585; PMCID: PMC8514021.

 Gaynes BN, Akiba CF, Hosseinipour MC, Kulisewa K, Amberbir A,

Udedi M, Zimba CC, Masiye JK, Crampin M, Amarreh I, Pence
BW. The Sub-Saharan Africa Regional Partnership (SHARP) for
Mental Health Capacity-Building Scale-Up Trial: Study Design and
Protocol. Psychiatr Serv. 2021 Jul 1;72(7):812-821. doi:
10.1176/appi.ps.202000003. Epub 2020 Dec 9. PMID: 33291973;
PMCID: PMC8187465.
 References – community-based mental health
initiatives in Malawi and Zimbabwe
 Mental Health Facilitator (MHF) Service Implementation in Schools in
Malawi, Africa: A Strategy for Increasing Community Human Resources.
Melissa Luke et al, TPC journal March 24, 2016

 Training primary health care workers in mental health and its impact on
diagnoses of common mental disorders in primary care of a developing
country, Malawi: a cluster-randomized controlled trial. Felix Kauye et al,
Cambridge University Press: 31 May 2013

 Why I train grandmothers to treat depression. Dixon Chibanda. TED

talk. YouTube 2018. https://m.youtube.com/watch?v=Cprp_EjVtwA