45 COMMUNITY PSYCHIATRY Chiam Peak Chiang

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Ralph Howard
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1 45 COMMUNITY PSYCHIATRY Chiam Peak Chiang Introduction Community care is the deployment of health and social services in settings, which meet patients needs, as far as possible, in their normal physical and personal environments. There should be a network of services that combines statutory, voluntary and self-help agencies, that are coordinated with the multidisciplinary teams liaising with primary care, accessible and user-responsive, offering choice, flexibility and accountability. Community psychiatry is based on the fact that people with psychiatric problems can be most effectively helped when links are maintained with family, friends, work colleagues and society in general. Because many patients and their relatives prefer psychiatric care to be provided in a community setting, services need to be organised in such a way that allows most patients to receive treatment near to their homes. With the availability of effective psychiatric medication, it is possible to treat most patients with psychiatric illnesses within the community. Only the acutely ill, disturbed or those with risks of violence or suicide need to be hospitalised. They should be discharged back to the community to continue further management once their conditions are stabilised. In order to maintain the patients in the community successfully, it is essential that community psychiatric services are affordable, comprehensive and accessible, otherwise problems like frequent relapses, vagrancy and other social problems may result. Coordination between the various agencies involved in community care is essential for services to be delivered effectively to the client. This involves adequate liaison between the hospital, social services, primary care workers, probation services, employment officers and voluntary organisations. As the needs and problems of psychiatric patients are varied and often complex, multi-disciplinary teams of professionals comprising psychiatrists, family physicians, psychologists, nurses, occupational therapists, social workers and physiotherapists in the government and voluntary organisations in liaison with each other are necessary. Advantages and Disadvantages of Community Psychiatry There are advantages and disadvantages associated with both community care and hospital care. When the patient is treated within the community, he lives within a natural environment and links with his community are maintained. Stigmatisation of being a mental patient is reduced. Community care also has the advantage of minimising the social and behavioural difficulties, as well as institutionalisation, which are often associated with living in a large mental institution. The patient may be more willing to seek psychiatric help if it is available within the community, thus enabling early detection and treatment of psychiatric illnesses. Community care, however, can be expensive due to the high cost of establishing the services. The stressors of everyday living may increase the likelihood of relapse in vulnerable patients. Violent and aggressive patients are less easily contained. If the support is inadequate, there is increased risk of homelessness and vagrancy. There may also be problems of coordinating the services resulting in fragmented resources and expertise. 1

2 Mental hospitals, on the other hand, can provide a supportive and protective environment. The risk of relapse due to environmental stressors is diminished. Disturbed patients are more easily contained. There is concentration of resources and expertise and the administrative structure is relatively easier to manage compared to community care. However, as mentioned earlier, hospital care increases the risk for institutionalisation and stigmatisation. The regime may be more authoritarian. The patients may have poorer access to the community. Types of Community Psychiatric Services 1 Outpatient Services Upon discharge from the wards, the patients need to be followed up at the outpatient clinics where their symptoms are monitored and therapy continued. It is also at the clinics that many patients seek psychiatric help for the first time. a. Family Physicians The family physicians being the front-line doctors whom patients usually consult first for any medical problem, are in the best position to pick up new cases of psychiatric disorders. Patients may be more willing to seek and receive psychiatric help from the family physicians as they may fear the stigma of being treated by psychiatrists. The family physicians can treat the milder forms of psychoses and neurosis, referring the more complicated cases or those requiring hospitalisation to the psychiatrists. Once discharged from the wards, it would be ideal that the family physicians continue to follow-up their patients. b. Psychiatric Outpatient Clinics There are psychiatric outpatient clinics located at many parts of Singapore, easily accessible to the patients. They are run by specialists attached to the various psychiatric hospitals and departments. Apart from the general psychiatric clinics, there are also subspecialty clinics like stress and anxiety clinics, mood disorder clinics, early psychosis intervention clinic, addiction behaviour clinics, child psychiatric clinics, geriatric psychiatric clinics, sleep disorder clinics, eating disorder clinics, sexual disorder clinics, psychotherapy clinics, neuropsychiatric clinics and trauma clinics. 2 Domicilliary Visits Domicilliary visits play an important role in maintaining psychiatric patients within the community. During the domicilliary visits, the patient and his home environment are assessed. Caregiver stress, abuse or neglect of the patients or caregivers may be detected and managed by the professional staff. a Community Psychiatic Nurse Services The Community Psychiatric Nurses is a team of nurses in Woodbridge Hospital who visit patients in their homes when they refuse or are unable to attend the outpatient clinics. They assess the patient s mental state, monitor side-effects and compliance with medication 2

3 and administer depot injections when necessary. psychoeducation and behavioural therapy. They also provide counselling, b. Doctors/Psychiatrists Home visits by the doctors are done to assess and manage the patients at home. This is particularly useful in the elderly person with dementia as he is less likely to be confused and distractable in familiar surroundings. This would enable more accurate assessments of his mental state and cognitive functioning. c. Medical Social Workers Home visits enable the medical social worker to better understand the patient s social circumstances so that the appropriate assistance can be rendered to the patient and his family. d. Occupational Therapists The occupational therapist can assess the patient s ability to cope with his activities of daily living at home. In the case of the confused elderly, the occupational therapist can give advice on home modifications that can improve safety for the patient. 3 Rehabilitation a. Day Centre Rehabilitation is important to enable the mentally ill to integrate back into society. Day centres provide social activities, sheltered workshop, day support and respite care, and vocational rehabilitation to optimise the current functional level of patients to prepare for employment. Activities often include contract work, craft, cooking, outdoor sports, discussion groups, social skills training, gardening, music and swimming. The occupational therapists also do on-site visits for patients who have been placed out to work. b. Dementia Day Centres These provide day care services for the elderly with dementia. They aim to provide relief for caregivers, increase families abilities to cope with and continue caring for their elderly with dementia, and to provide social activities, occupational therapy and physiotherapy for the dementia sufferers. Activities include physical exercises, social activities, simple art and craft, cooking, reminiscence therapy and reality orientation. 4 Support Groups Support groups allow social, recreational and educational activities of mentally ill persons. This helps to develop their interpersonal relationships, social skills and self-esteem and confidence to improve their social functioning. 3

4 Family support groups bring together care-givers and significant others to share their experiences and learn from one another about looking after the mentally ill person in the family. 5 Hostels Hostels provide accommodation on a short-term basis to mentally stabilised patients who still have difficulty adjusting to society and do not have the confidence to function independently. At the hostels, meals, counselling and rehabilitation in the form of vocational training, social and organisation skills are available to equip the patient to cope with life within the community. 6 Group Homes Group homes provide accommodation for mentally stable patients who are gainfully employed and who will benefit from independent living because they have no place to stay or because of adverse factors in the family. The Singapore Association for Mental Health Group Homes are Housing and Development Board flats where several patients share rental and living arrangements. 7 Hotlines and Counselling Service Hotlines and counselling services provide a listening ear to anyone who needs to discuss problems and disputes, obtain counselling and advice, information and referral assistance. Those who contact the hotlines may remain anonymous if they wish, or they may choose to reveal their identity and to meet a counsellor face to face with no obligations attached. The Samaritans of Singapore also provide emergency service for immediate suicide cases apart from the toll free 24-hour emergency telephone service and face-to-face counselling. Conclusion Both mental hospitals and community psychiatric services are important in providing the continuum of care for the psychiatric patients. As more and more psychiatric patients expect to be treated outside of mental hospitals, community psychiatry services need to be continuously developed to meet the needs of the patients. 4

5 Services 1 Psychiatric Outpatient Clinics a. Woodbridge Hospital Clinic B, Woodbridge Hospital 10 Buangkok View Singapore Tel: Behavioural Medicine Clinic Institute of Health 3 Second Hospital Avenue Singapore Tel: Alexandra Behavioural Medicine Clinic 141 Viking Road Singapore Tel: Geylang Behavioural Medicine Clinic 21 Geylang East Central Singapore Tel: Tampines Behavioural Medicine Clinic 1 Tampines Street 41 Singapore Tel: Choa Chu Kang Behavioural Medicine Clinic 2 Teck Whye Crescent #03-00 Singapore Tel: Toa Payoh Behavioural Medicine Clinic 2003 Lorong 8 Toa Payoh Singapore Tel: Child Guidance Clinic Institute of Health 3 Second Hospital Avenue Singapore Tel:

6 b. National University Hospital Neuroscience Clinic Department of Psychological Medicine 5 Lower Kent Ridge Road Singapore Tel: c. Tan Tock Seng Hospital Department of Psychological Medicine Specialist Clinic Specialist Clinical Suites 11 Jalan Tan Tock Seng Singapore Tel: d. Changi General Hospital Clinic E Department of Psychological Medicine 2 Simei Street 3 Singapore Tel: e. Singapore General Hospital Psychogeriatric Clinic E clinic Outram Road Singapore Tel: f. Alexandra Hospital Psychological & Addictive Medicine Services 378 Alexandra Road Singapore Tel: (Psychogeriatric Clinic) (Addiction Clinic) 2 Day Centres a. Psychiatric Day Centres Institute of Mental Health Day Centre 10 Buangkok View Singapore Tel

7 Alexandra Day Centre 620 Tiong Bahru Road Singapore Tel Bukit Batok Day Centre 50 Bukit Batok West Avenue 3 Bukit Batok Polyclinic Level 3 Singapore Tel Balestier Care Centre 3 Pegu Road Singapore Tel: Elliot Road Care Centre 1 Elliot Road Singapore Tel: b. Dementia Day Centres New Horizon Centre (Bukit Batok) 511 Bukit Batok Street 52 # Singapore Tel New Horizon Centre (Toa Payoh) 157 Toa Payoh Lorong 1 # Singapore Tel: Apex Harmony Lodge 10 Pasir Ris Walk Singapore Tel SWAMI Home Dementia Day Care Centre 5 Sembawang Walk Singapore Tel Sunlove Abode for Intellectually Infirmed Ltd Trafalgar Units 461 Lor Buangkok Singapore Tel

8 Ju Eng Home Day Centre 205 Jalan Kayu Singapore Tel: Support Groups Oasis Centre Singapore Association for Mental Health 139 Potong Pasir Avenue 3 # Singapore Tel: Family Support Group Singapore Association for Mental Health 139 Potong Pasir Avenue 3 # Singapore Tel: Hostels East Coast Care Centre (men) 511 East Coast Road Singapore Tel: The Bougainville (women) 1 Elliot Road Singapore Tel: Group Homes SAMH Group Homes Block 239 # & Block 240 # Bukit Batok East Avenue 5 Singapore Tel: Counselling Centres and Hotlines Samaritans of Singapore 18 Outram Park #03-21 Singapore Tel: (Administration) Hotline: (24 hours daily) 8

9 SAGE Counselling Centre 19 Toa Payoh West Singapore Tel: Hotline/Helpline: Singapore Anti-Narcotics Association Hotline/Helpline: (Malay/English) (Chinese/English) Singapore Association for Mental Health 69 Lorong 4 Toa Payoh # Singapore Tel: Hotline/Helpline: Counselling and Care Centre 536 Upper Cross Street Hong Lim Complex # Singapore Tel: National University Hospital Stress Hotline Tel: Teenage Crisis Centre Teen Challenge Tel: Youthline Youth Challenge Tel: Care Corner 800 Hotline Care Corner Mandarin Counselling Centre Tel: Eating Disorders Helpline Tel: Alcoholic Anonymous Tel: (Answering Machine) SAF Hotline SAF Counselling Centre Tel:

10 References 1 Robert I Cohen and Jerome J Hart. Student Psychiatry Today a Comprehensive Textbook. Butterworth Heinemann (2 nd Ed), Louis Appleby and David Michael Forshaw. Postgraduate Psychiatry: Clinical and Scientific Foundations. Heinemann Medical Books, Douglas Bennet and Hugh L Freeman. Community Psychiatry. Churchill Livingstone, Jerome V Vaccaro and Gordon H Clark. Practicing Psychiatry in the Community a Manual. American Psychiatric Press, Directory of Social Services. Compiled by the National Council of Social Services, Membership Development Division (7 th Ed),

COMMUNITY CASE MANAGEMENT SERVICE

COMMUNITY CASE MANAGEMENT SERVICE Community Case Management Service aims to enhance the quality of life of the needy elderly by providing on-going support to help them to remain autonomous in their own