Community Psychiatry

   (See Beers, Clifford; also Psychotherapy: group psychotherapy; "therapeutic community" [both 1939].)

   The premise of community psychiatry is that patients with serious illnesses are best treated in the community rather than in closed mental hospitals. Although this preference had been adumbrated throughout the nineteenth and early twentieth centuries, only in the 1940s does it start to swell into a movement. Particular landmarks in the unfolding of the community approach are given below.

   The Mental Health Treatment Act of Great Britain (1930). The act provided for voluntary treatment in mental hospitals so that patients might be less resistant to admission if they could leave at will; the act also authorized outpatient clinics based in asylums and general hospitals; indeed, the act discarded the term "asylum" in favor of "mental hospital."

   "Day hospitals" (from 1946). As notions of "therapeutic community" expanded after the Second World War, it became apparent that the community needed a site where discharged patients in particular could be treated during the day without being formally admitted to a psychiatric bed. D. Ewen Cameron (1901–1967), head of psychiatry at McGill University, created the first day hospital in the world in 1946 at the Allan Memorial Institute in Montreal. In 1948, psychotherapist Joshua Bierer (1901–1984) established the first in England, a "social club" at the Social Psychiatry Centre in London that he had set up 2 years previously. A number of other such day hospitals then followed in Great Britain, so that by 1959 more than 38 existed. The movement incorporated Bierer’s philosophy that, "Treatment must include the whole social environment of the patient and all his social relationships. He must be treated not only as a person but as part of a community," as he wrote in the Lancet in 1959 (p. 901).

   The Community Mental Health Centers Act in the United States (1963). Stimulated by the report Action for Mental Health in 1961 (see Psychotherapy: "therapeutic community"), in 1963 Congress passed an act designed, as Robert Felix, head of the National Institute of Mental Health, put it, "to reduce substantially, within a decade or two, the numbers of patients who received only custodial care—or no care at all—when they could be helped by the application of . . . the modern methods of dealing with . . . mental illnesses." Yet the program was never adequately funded, and many centers became diverted toward psychotherapy for middle-class people with adjustment disorders rather than looking after recently discharged patients with serious illnesses. In the words of psychiatry historian Gerald N. Grob, "Within a decade after the passage of the act of 1963, it had become clear that CMHCs, whatever their original purposes, had neither replaced mental hospitals nor provided alternative services for the severely mentally ill" (From Asylum to Community, p. 256).

   The promotion of "community mental health services" by the Regional Office for Europe in Copenhagen of the World Health Organization (from 1970).

   The efforts of the World Health Organization (WHO) Regional Office for Europe had a large impact on community psychiatry in Europe, particularly from the viewpoint of (1) implementing community care programs based on the principles of "continuity of care" (up and down the ladder of referral from mental hospital to community), (2) creating "integrated care" (meaning a number of different mental-health disciplines and institutions collaborating smoothly), and (3) augmenting the resources given to mental health. As a WHO report in 1971 noted, "The trend towards caring for the mentally ill in the community wherever possible and recognition of the need to consider the patient in the context of his social environment are modern phenomena. This approach is the antithesis of custodial care in large isolated institutes and of an exclusively medical approach which seeks to treat mental illness in the same terms as a physical disease" (WHO, Trends in Psychiatric Care: Day Hospitals and Units in General Hospitals, p. 18).

   The advent of the "depot" antipsychotics (from 1973). A major obstacle to community psychiatry had been the reluctance of many discharged schizophrenic patients to continue taking their antipsychotic medications because of the movement disorders known as "extrapyramidal side effects" that often accompany chronic use of antipsychotics. (See also Parkinsonism: Neuroleptic-Induced; Tardive Dyskinesia.) Once these patients discontinue their medications, they relapse easily and become resistant to the ministrations of community care. Thus, the Squibb company’s introduction in 1973 of long-acting fluphenazine, marketed as Prolixin Decanoate, an injectible form of the drug—dissolved in oil, allowing for slow release—that acts for up to a month (instead of having to be taken daily), had a big impact on community psychiatry. As a World Rehabilitation Fund report commented in 1986, "Easily accessible depo-neuroleptic clinics dispense these medications to patients living in the community and patients appear less resistant to medication maintenance."