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Global Mental Health Reforms
Published Online: 2 March 2020

Community Engagement Mental Health Model for Home Treatment of Psychosis in Jamaica

Abstract

Economic constraints in low- and middle-income countries like Jamaica challenge health care services to identify efficient methods of mental health care. This column describes the community engagement mental health (CEMH) model in Kingston, Jamaica, for patients with mental disorders, including psychosis. The CEMH uses a task sharing methodology to deliver acute psychiatric treatment within a community setting. Preliminary results suggest high service user and provider satisfaction and good clinical outcomes. The authors discuss challenges and benefits of the CEMH in terms of its potential as a cost-effective service innovation.

HIGHLIGHTS

There is a great need to identify cost-effective community services for mental illness in low- and middle-income countries to offset the burden of mental disorders on institutions.
In Jamaica, the community engagement mental health (CEMH) model uses a community-based, task sharing methodology with a focus on social functioning and inclusion as an alternative to hospital care.
Advantages to the CEMH include service users’ and providers’ satisfaction with the services, a high degree of social functioning, and reduced burden on institutions despite the high prices for newer psychopharmaceuticals.
The contribution of psychiatric disorders to the global burden of disease has increased over recent decades. Psychiatric disorders now account for a greater proportion of readmissions to hospitals than do nonpsychiatric disorders, placing greater demand on health care facilities around the world (1). To reduce the burden on facilities, countries around the globe have made it a priority to decrease cumulative hospital stay for acute mental illness. Mobile treatment and assertive outreach programs have been developed as alternatives to hospitalization. These programs have had varying degrees of success, and participation is usually enforced through legal processes, which diminishes the agency of the client (2).
Jamaica, an upper-middle income country in the Caribbean, has followed the global decentralization trend. Since gaining its political independence in 1962, Jamaica has undertaken a process of gradual deinstitutionalization of Bellevue Hospital (BVH), the nation’s only public psychiatric hospital. The country has shifted its admission patterns to BVH, and primary and secondary care services have become the main framework of care of persons with mental illness, in keeping with the mandate of the World Health Organization for mental health care in low- and middle-income countries (LMICs) (3). This evolution in care has led to the development of the community engagement mental health (CEMH) model, an innovative islandwide community mental health service. Psychiatric hospital usage has gradually declined, resulting in a fourfold reduction in the patient population at BVH (4).
This fully integrated primary health care model has gained international attention as an effective treatment strategy. The model establishes a process that focuses on social inclusion and collaboration with clients. By focusing on social functioning and inclusion, the model counters the criticism levied at the first world’s deinstitutionalization process, which deconstructed the asylum while retaining paternalistic and institutionalized philosophical approaches to care (5).

The CEMH Model

The CEMH service has no psychiatric beds and operates public mental health clinics in outpatient departments and health centers in one of Jamaica’s four regional health authorities, providing acute crisis response and home treatment to a geographical population of 700,000. The staff consists of three psychiatrists, three mental health nurse practitioners, 12 mental health officers, and 25 psychiatric aides. Mental health officers are registered nurses who have undergone further psychiatric nursing and management training and are legally mandated to deliver community-based care semi-autonomously, under the supervision of psychiatrists. Mental health nurse practitioners have the additional qualification of a master’s degree in mental health nursing. The service was developed to reduce inpatient burden through primary prevention and community-based crisis management in which family, community members, and the patient collaborate with providers in the management of the patient’s illness (6). The model is assimilated both administratively and legally into the primary care system.
In the CEMH model, social functioning and inclusion are viewed as the primary outcome, and symptom relief is considered secondary. Rather than sequestering the patient in a mental health facility, service providers encourage patients to maintain their social responsibilities, and they provide support when patients are not able to fulfill these responsibilities on their own. Patients are therefore able to maintain self-sufficiency and not become a burden on the state-run disability programs. This community-centered focus also serves to enhance the therapeutic relationship between the client and the treatment service providers, a relationship that is vulnerable to disintegration in legislatively centered interventions (7).
The CEMH model uses a task sharing model that shifts the delivery of specific interventions from the psychiatrist to the mental health officers and mental health nurse practitioners and allows the psychiatrist, who serves in a more administrative and clinical supervisory role, to manage a larger client base. Through psychoeducation and supervised contact, community members, families, and patients are able to develop social support networks that provide monitoring and delivery of psychosocial care in acute episodes and in the maintenance phases of treatment. In this way, Jamaica is moving in the direction of other LMICs, which have been encouraged to adopt task sharing as a way to bridge the treatment gap for delivery of mental health services (8).
This delivery system provides an alternative to the existing inpatient services for acutely ill patients with first-episode psychosis (FEP). Patients with FEP would otherwise present at BVH, the University Hospital of the West Indies (UHWI), or Kingston Public Hospital (KPH). BVH offers 90 beds for acute admission, UHWI has 20 beds in a closed general hospital unit, and KPH has 10 psychiatric beds in open general medical wards.
Preliminary data for patients with psychotic disorders, who make up the majority of users of mental health services on the island, have shown that there were no differences in clinical improvement over time and relapse rates between the CEMH and acute hospital inpatient treatment. Yet the institutional burden of CEMH is much lower, given the community treatment design and the focus on empowering the community, family members, and the patient to actively participate in the management of the illness.
Since implementation of the model, patient utilization has increased significantly over time in the South Eastern Regional Health Authority compared with other regions. (A figure comparing the number of patients with psychosis in each region is available in an online supplement.) If these preliminary findings are supported by sufficiently powered studies, the public policy significance is profound, particularly when considering that acute inpatient treatment costs more than outpatient treatment.

Lessons Learned

Addressing the mental health gap presents larger challenges in LMICs than in developed countries. Resource constraints have a significant impact on whether LMIC countries can successfully translate mental health models from developed countries. It is therefore relevant to develop country-specific or region-specific interventions in conjunction with a global mental health approach. For example, to maintain the collaborative nature of the therapeutic relationship, the CEMH model often uses second-generation antipsychotic pharmaceutical agents, which are tolerated better than first-generation antipsychotics. This presents a significant challenge, given that the second-generation medications are associated with significantly higher costs (9). The compliance and stability afforded by this practice, however, minimize hospital bed occupancy and associated inpatient costs, balancing out the added cost of medication.
The shift in philosophical approaches from custodial to collaborative care was met with psychological resistance by many stakeholders, including the team members the team members, who were accustomed to what they considered best practices. This reaction was addressed in a sensitization and retraining session that used group cultural therapy techniques developed by Hickling et al. (10). These techniques facilitate the engagement and processing of politically volatile and sensitive topics in group discussions and help participants arrive at consensus (11).

Conclusions

Preliminary findings suggest that the Jamaican community engagement model of home care treatment of patients with acute psychotic disorder may be a viable alternative to costly and labor-intensive inpatient care. This is an imperative issue for LMICs, which have had difficulties establishing a path to deinstitutionalization (12). We recommend that this study be extended as both a large-scale study as well as a more longitudinal evaluation of patient service utilization patterns.

Footnote

Dr. Nelson was sponsored by Janssen Pharmaceuticals for travel to the American Psychiatric Association Research Colloquium in 2017. The other authors report no financial relationships with commercial interests.

Supplementary Material

File (appi.ps.201900063.ds001.pdf)

References

1.
Whiteford HA, Degenhardt L, Rehm J, et al: Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 2013; 382:1575–1586. doi: 10.1016/S0140-6736(13)61611-6
2.
Keown P, Tacchi M, Niemiec S, et al: Changes to mental healthcare for working age adults: impact of a crisis team and an assertive outreach team. Psychiatr Bull 2007; 31:288–292. doi: 10.1192/pb.bp.106.012054
3.
Hickling FW: Community psychiatry and deinstitutionalization in Jamaica. Hosp Community Psychiatry 1994; 45:1122–1126
4.
Hickling FW, Walcott GO: The Jamaican LMIC challenge to the biopsychosocial global mental health model of Western psychiatry; in Innovations in Global Mental Health. Edited by Okpaku S. Cham, Switzerland, Springer, 2019
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Chow WS, Priebe S: Understanding psychiatric institutionalization: a conceptual review. BMC Psychiatry 2013; 13:169. doi: 10.1186/1471-244X-13-169
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Jorm AF: Mental health literacy: empowering the community to take action for better mental health. Am Psychol 2012; 67:231–243
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Kisely SR, Campbell LA, O'Reilly R: Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 17;3:CD004408
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Hoeft TJ, Fortney JC, Patel V, et al: Task‐sharing approaches to improve mental health care in rural and other low‐resource settings: a systematic review. J Rural Health 2018; 34:48–62
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Nasrallah HA: The roles of efficacy, safety, and tolerability in antipsychotic effectiveness: practical implications of the CATIE schizophrenia trial. J Clin Psychiatry 2007; 68(suppl 1):5–11
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Hickling FW: Psychohistoriography: A Post-colonial Psychoanalytical and Psychotherapeutic Model. London, Kingsley, 2012
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Hickling FW, Guzder J, Robertson-Hickling H, et al: Psychic centrality: reflections on two psychohistoriographic cultural therapy workshops in Montreal. Transcult Psychiatry 2010; 47:136–158
12.
Mundt AP, Chow WS, Arduino M, et al: Psychiatric hospital beds and prison populations in South America since 1990: does the Penrose hypothesis apply? JAMA Psychiatry 2015; 72:112–118

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Pages: 522 - 524
PubMed: 32114944

History

Received: 1 February 2019
Revision received: 11 December 2019
Accepted: 18 December 2019
Published online: 2 March 2020
Published in print: May 01, 2020

Keywords

  1. Psychiatry/general
  2. Community mental health services
  3. Deinstitutionalization
  4. Psychosis
  5. Home Treatment

Authors

Details

Danielle Nelson, D.M.
South East Regional Health Authority, Ministry of Health of the Government of Jamaica, Kingston (Nelson); Faculty of Medical Sciences, University of the West Indies, Mona, Jamaica (Walcott, Walters, Hickling); Caribbean Institute of Mental Health and Substance Abuse, Kingston (Walcott, Hickling). Kathleen M. Pike, Ph.D., and Pamela Scorza, Sc.D., M.P.H., are editors of this column.
Geoffrey Walcott, D.M. [email protected]
South East Regional Health Authority, Ministry of Health of the Government of Jamaica, Kingston (Nelson); Faculty of Medical Sciences, University of the West Indies, Mona, Jamaica (Walcott, Walters, Hickling); Caribbean Institute of Mental Health and Substance Abuse, Kingston (Walcott, Hickling). Kathleen M. Pike, Ph.D., and Pamela Scorza, Sc.D., M.P.H., are editors of this column.
Christine Walters, Ph.D.
South East Regional Health Authority, Ministry of Health of the Government of Jamaica, Kingston (Nelson); Faculty of Medical Sciences, University of the West Indies, Mona, Jamaica (Walcott, Walters, Hickling); Caribbean Institute of Mental Health and Substance Abuse, Kingston (Walcott, Hickling). Kathleen M. Pike, Ph.D., and Pamela Scorza, Sc.D., M.P.H., are editors of this column.
Frederick W. Hickling, D.M.
South East Regional Health Authority, Ministry of Health of the Government of Jamaica, Kingston (Nelson); Faculty of Medical Sciences, University of the West Indies, Mona, Jamaica (Walcott, Walters, Hickling); Caribbean Institute of Mental Health and Substance Abuse, Kingston (Walcott, Hickling). Kathleen M. Pike, Ph.D., and Pamela Scorza, Sc.D., M.P.H., are editors of this column.

Notes

Send correspondence to Dr. Walcott ([email protected]).

Competing Interests

No external sponsor provided any sponsorship or input into the conceptualization, implementation, data collection, analysis, write-up, or reporting of this research.

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