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

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.