Innovation summary

This program aims to address colonial, centralized, custodial and stigmatizing approaches to treating mental illness.

The goal is to provide liberating, humanizing, efficacious, cost effective and culturally appropriate treatment for mental illness. This is achieved by integrating mental health into all levels of the health system – including general hospitals, primary care and the community – to provide accessible and affordable mental health care to the entire population.

Impact summary

  • In 2010, 56,175 people were treated in community clinics with 2,163 general hospital admissions, compared to 1059 admissions to the mental hospital in 1960 with 3,094 inpatients
  • The psychiatric mental hospital inpatient population has fallen from 3,094 in 1960 to 756 in 2010 without concurrent increases in the number of mentally ill people who are homeless or in prison

A health center is not only for mental illness but is for maybe a range of health issues so therefore it is not considered to be as serious. It is like you are just going for a regular check up.

 

- Female patient Kingston

Innovation details

This innovation aims for the integration of community mental health with primary and secondary health care services and the treatment of severe acute mental illness on the open medical wards of general hospitals.

It also wants to see the abolition of custodial care facilities for the mentally ill in Jamaica. No long-stay or medium-stay facilities exist in the island. By law, 28 days is the maximum length of stay that a patient can be held involuntarily in hospital.

The final goal of the project is the establishment of Cultural Therapy based on the novel analytic technique – psychohistoriography. This method has morphed into the present wave of multi model-therapy for children and adults that is now being called Community Engagement.

This innovation’s most effective features include:

  • Fostering creative and visionary leadership of indigenous mental health practitioners
  • Island-wide integration of mental health services into the public health services of the country
  • Geographic catchment areas  of mental health services created island-wide
  • Extensive integration of psychiatry with Internal Medicine and Public Health Medicine at a private and public level
  • Abolition of medium and long term custodialization of the mentally ill
  • Significantly reduce the costs of managing acute and enduring mental illness
  • Development of culturally appropriate methods of treating mental illness
  • Diversion of treatment of the mentally ill offenders from the Correctional Services
  • Reduction in stigma towards the mentally ill in the community
  • A large increase of the number of mental health professionals (psychiatrists, psychologists, mental health officers and psychiatric nurse practitioners) in the country over 50 years
  • Reversing the mental health professional brain-drain
  • Facilitation of private/public collaboration at all levels of clinical practice

Key drivers

Training 

  • Training psychiatrists and other mental health professionals in the homeland made the innovation spread quickly and easily

Early integration

  • Early integration of trained mental health professionals into both the clinical and administrative health and mental health facilities in the country
  • Ensuring and maintaining clinical success (outcome and safety) at every level of community integration of mental health services

Development

  • Encouraging the development of private community mental health care facilities
  • Assisting in  the development of community mental health organizations and associations in the country
  • Facilitating the development and growth of mental health research and publication
  • Incorporating mental health promotion as a sine qua non of clinical and administrative practice

Challenges

  • Resistance from clinicians and administrators at every level of practice
  • Transformation of mental health legislation
  • Dismantling the administrative and clinical organization of the mental hospital

Continuation

Varying parts of this process have been implemented in every Anglophone Caribbean territory over the pasts 50 years with significant success. The deinstitutionalization process has been the most difficult component of the innovation to implement, partly due to the economic and administrative benefits for the workers entrenched in these institutions.

Future plans include:

  • Continuing to train mental health professional at every level
  • Continuing to develop specialized facilities such as child mental health facilities, substance abuse facilities, forensic facilities
  • Continued integration of mental health into health and public health services
  • Scale up of recent development of primary preventative services within schools and within the community

Partners

Funders:  

  • The Jamaican people

Evaluation methods

Two situational needs analyses were conducted, one in 1999 and on in 2005.

A Review conference is held by the Ministry of Health annually.

Cost of implementation

The innovation process has been going on for nearly fifty years and has involved a significant sector of the health and mental health budget of the country for that period, and the entire psychiatric teaching/training budget of all health professionals in the country.The financial records for mental health are not robust enough to express detailed costs of mental health services.

The annual budget for the Bellevue Mental Hospital in 2012 was 6% of health budget, whereas the Community Mental Health budget for the entire island for the same year was 17% of total mental health budget. However, this latter figure does not include the hidden costs for the admission of patients to medical wards in general hospitals, or the budget for private mental health facilities in the country.

The budget to develop the Community Mental Health Services has come primarily by transferring from the mental hospital budget.

Impact details

Treatment

  • The psychiatric mental hospital inpatient population has fallen from 3,094 in 1960 to 756 in 2010 without concurrent increases in the number of mentally ill people who are homeless or in prison
  • In 2012, 105 clinics located in every parish community across the island serve the population of 2.7 million

Impact  

  • Psychiatric admissions have shifted predominantly to the general hospitals; the mental hospital beds have diminished exponentially (a decrease from 192.2 beds per 100,000 in 1960 to 25.9 per 100,000 in 2010) and the community coverage has increased proportionately over the same period
  • In 2011, 3 in 4 psychiatric hospital admissions were to psychiatric or general wards in general hospitals. Only 1 in 4 were admissions to a psychiatric hospital
  • In 2010, 56,175 people were treated in community clinics with 2,163 general hospital admissions
  • In 1965 there were 4 psychiatrists, 4 mental health officers, 1 psychologist and 2 psychiatric social workers serving the population of 1.7 M people. Since 1965, professional training has realized 40 psychiatrists, 100 mental health officers, 15 psychiatric nurse practitioners, 400 community psychiatric aids and 108 clinical psychologists who now serve the population of 2.7M. All psychiatrists trained locally apart from 1 have remained in Jamaica

Outcome

  • Deinstitutionalization and integration of mental health services into general health care has reduced stigma towards mental illness in Jamaica1,2

References

1. Gibson RC, Abel WD, White S, Hickling FW. (2008)Internalizing stigma associated with mental illness: Findings from a general population survey in Jamaica. Rev Panam Salud Publica, 23(1):26–33  http://www.ncbi.nlm.nih.gov/pubmed/18291070 (accessed 04/12/2013)

2. Hickling FW, Robertson-Hickling H, Paisley V. (2011)  Deinstitutionalization and attitudes toward mental illness in Jamaica: a qualitative study. Rev Panam Salud Publica, Mar;29(3):169-76. 12 http://www.ncbi.nlm.nih.gov/pubmed/21484016 (accessed: 04/12/2013)

Research

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