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For
a long time, psychiatric care was available only
in mental hospitals, which were far removed from
other hospitals and even cities. One accompaniment
of the de-institutionalization of psychiatry was
its acceptance in general hospital settings.
The next logical step in the same direction was
integration of psychiatry in the primary health
care. This integration aimed at the application
of psychiatric knowledge by the medical and paramedical
personnel of the primary health care settings
to provide at least basic mental health care.
It
has been noticed that most of the medical facilities
are concentrated in the big cities and the primary
health centers suffer from an acute shortage of
doctors and other medical facilities. In this
backdrop the brunt of the treatment has to be
borne by the paramedical professionals who takes
care of health of the majority population in the
village.
The
capability of the paramedical professionals and
health care workers in the delivery of health
care at the
Primary
level has been proved beyond doubt. While the
doctor still remains the leader of the team, suitably
trained workers can take responsibility for a
considerable proportion of the work. The involvement
of health workers in the delivery of the mental
health care has been relatively recent development.
Several experimental models have demonstrated
that health workers, after a brief training, can
acquire basic skills for basic mental health care.
Applying
the broad principles of primary care in the context
of mental health, the following issues need emphasis.
1.
Equitable distribution.
Health care services should be accessible to all
section of the society, with special attention
to the vulnerable and needy. Mental health services
are distributed so unequally, especially in the
developing countries, that there is urgent need
for their equitable distribution. This cannot
be achieved without providing mental health care
as a part of the primary health care level.
2.
Preventive approach.
It may be conceptualized as primary (general and
specific measures to prevent illnesses and to
promote health), secondary (early detection and
prompt treatment) and tertiary (reduction of disability
and optimum rehabilitation). Mental health care
can contribute towards all these components. It
has been estimated that 50 % of neurological and
mental illnesses are preventable by existing knowledge.
3.
Multisectorial efforts. Health cannot
be attained and maintained by the health sector
alone. Participation of other sectors like education,
public works, housing, social welfare and law
is essential. In the case of mental health, these
sectors are of paramount importance as they can
play a vital role in the prevent ional and promotional
activities.
4.
Community participation. Involvement
of individuals, families and communities is desirable
for a successful rural health care program. This
is even more true for mental health care program
because family and community play important roles
in causation, detection and continued care of
the mentally sick.
EPIDEMIOLOGY
OF PSYCHIATRIC ILLNESS
The
prevalence and pattern of psychiatric illness
has been studied in some developed countries for
last few decades. Initial studies from U.K. ,where
general practitioner system has long been in existence,
revealed that about 10 to 15 % of the registered
patients in the practice area and about 8 to 30
% patients consulting the doctors were suffering
primarily from a psychiatric illness. In another
landmark study , the same group of workers showed
that the total psychiatric morbidity in a general
practice sample of more than 14000 individuals
was almost 140 per thousand. Out of which,102
per thousand were assigned a formal psychiatric
diagnosis. Women are almost twice as likely to
have a psychiatric diagnosis as men. A majority
of
these case is diagnosed as neurosis, psychosis
was diagnosed in 5.8 and alcohol and drug addiction
in 2 per thousand individuals. In another study
, Goldberg and Blackwell found that conspicuous
psychiatric morbidity among general practice patients
was about 20%. It was further been estimated that
the general practice consultation for identified
psychiatric disorders out number psychiatric outpatient
attendance by 10:1, and psychiatric admissions
by 100:1 .
In
a study from Bangladesh , 40% of the patients
were found to have mental morbidity. Studies from
Kenya and Sri Lanka also report 15 to 30% patients
as having psychiatric morbidity.
The
prevalence studies in India have shown that at
any given time, 1-2 % of the population suffers
from psychiatric disorders which require urgent
attention. Moreover, it is also estimated that
15 to 20 % of the general population of any health
facility requires psychiatric help. Mentally retarded
individuals constitute nearly 3 % of the population.
Neki has reported that 27% of the out patients
need psychiatric help, while Murthy has reported
that 36% of the general practice patients require
psychiatric treatment. Integration of the
mental health care with the general health care
has been advocated by W.H.O.
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