The development of a community-based comprehensive mental health service delivery system for the Cayman Islands (1989-2001)

This paper reviews the development of mental health services in the Cayman Islands throughout a twelve-year period (1989 to 2001). I was appointed the resident consultant psychiatrist to the islands in 1989, after which time a consultative process between the Ministry of Health, Senior Management of the George Town Hospital and myself allowed the development and establishment of a comprehensive community-based mental health service delivery system (MHSDS), specifically designed to suit the needs of the Cayman Islands. The framework for the service is outlined, and the concerns and objectives of the MHSDS are discussed, along with short-term and long-term goals. (AU)

A retrospective study and profile of new cases attending the child guidance clinic, Bustamante Hospital for children, between September 1998 and February 1999

A total of 72 cases who attended the Child Guidance clinic at the Bustamante Children Hospital between the six months period of September 1998 and February 1999 were investigated in a retrospective study, using their case notes. The age of cases ranged from 3 years to 17 years with the mean age of 8.8 and most frequent age group being 6 to 10 years (58.3 percent). More cases were males (52.4 percent) and most of them came from St. Catherine. The majority of cases (48.6 percent) were attending Primary school and most of them were referred by other hospitals (36.6 percent) and private clinics (21.1 percent). The mothers were the most frequent informants (64.8 percent) who were living with the children more often than fathers (59.7 percent vs 12.3 percent). The most common presenting problem was aggressiveness (43.1 percent) where as Attention Deficit Hyperactivity Disease (ADHD) was diagnosed most often (20.8 percent). The majority of children were born of unplanned pregnancies (71.4 percent of recorded cases). Only 30 cases had both parents living in the same household. 19.4 percent of cases were abused, among which sexual abuse was the most common form. Out of 26 cases recorded for psychosocial stressors, witnessing violence (22.2 percent) was the most common stessor and exposure to gunmen accounted for (6.9 percent) of these cases. Over half 53.7 percent of the cases recorded were separated from fathers. Fathers were also the ones who did not support nor contact their children much, whereas mothers tend to support and contact their children more regularly when not living together. Most of these findings showed and suggested the need of children to be attached and receive the love, care affection and attention from both parents, their mothers and also their fathers (AU)

Integrated primary mental health care

Mental health is increasingly being recognised as contributing significantly to the burden of disease, particularly now that the indicators have shifted from measures of mortality to measures of morbidity. Psychiatric morbidity in the community, based on community surveys, is estimated at 20 to 30 percent of the population. Increasingly, patients needing health services prefer to be in a general health care setting than in specialized centres. Internationally and regionally, the general policy has been to move toward the development of comprehensive mental health programmes integrated within primary health care. This integration may be structural (use of shared facilities), administrative (shared administrative resources) or functional (complete integration of clinical services, with staff jointly responsible for patient welfare). This paper examines how this integration can be achieved, and the potential role of the Department of Community Health and Psychiatry, University of the West Indies in advancing this integrative process through research and training.(AU)

Mental health in the Caribbean

Mental health is a term that is seldon used, but mental illness and mental disorder are expressions used by everyone. The phrase 'he/she is mental' is an indication that a person has a disturbed mind and may be in need or hospitalization, whether at a general hospital or a mental institution. There is no doubt that each country must deal with those psychotic individuals who have become a public nuisance, but we need to consider mental health and not just severe mental illness. Only a very small part of the general population suffers from psychotic illness but mental health issues cover a wide range of psychosocial factors and are of major importance in the development of any country. More emphasis must be put on developing community mental health programmes and less on institutional care. The areas of greatest concern to the public - drug abuse, childhood disorders and the increase in suicide - should be handled by specialist, who would then be responsible for building up appropriate services though use of the team approach (AU)

School violence reduction: a model Jamaican secondary school program

Violence in United States' schools is epidemic. Solutions are rare. Community mental health centers are now being challenged to become part of the solution. The Montego Bay Secondary School project presents an example of how violence reduction can be achieved using almost no physical resources and the special effect, called the "Bruno Effect", created by one Jamaican police offficer with the consultation of a psychodynamically-led training and intervention team. The "Bruno Effect" resulted in a dramatic reduction in the number of physical attacks from an observed 5 fights per day (3 out of the 5 involved knives and cuttings) to 1 per week. The violence rate returned immediately to its former level as soon as "Bruno" left the school. The dramatic violence reduction appears related to establishing an adult protective shield. Results stem from the unique personality of the adult protector, as well as a combination of the special role of the police and the outside intervention team.(AU)

A comparison of US-born African-American and African-Caribbean psychiatric outpatients

This study compares US-born African Americans with African Caribbeans attending an urban psychiatric outpatient clinic on various items pertaining to sociodemographics, psychiatric history, current psychiatric illness, and physical health. A structured chart review was performed on a sample comprised of 135 native-born African Americans and 91 African Caribbeans who had attended the clinic during an 11-year period. A total of 28 clinical variables were examined. Nine clinical variables were found to significantly differentiate the two groups in bivariate analysis, and these were entered along with three demographic control variables into a logistic regression analysis. Seven variables attained significant independent effects. African Americans were differentiated from African Caribbean on history of greater alcholic abuse or dependence, presence of more delusions, worse health, longer history of previous outpatient treatment, and greater clinical improvement at 6 months. African Caribbeans were found to have a greater frequency of depression and aggressivity. These data underscore the importance of examining intraracial differences in mental illness as well as pointing to the potential benefits of using intraracial comparisons to interpret interracial analyses.(AU)

Community psychiatry and deinstitutionalization in Jamaica

Between 1960 and 1990, the population of Jamaica's single mental hospital was reduced by 58 percent, from more than 3,000 to less than 1,300. Services were reoriented from mental-hospital-based custodial care to rehabilitative, community-based care with no appreciable increase in the mental health budget. Despite several changes in government over the past 30 years, continuity of public policy and fiscal support has allowed ongoing development of the island's community mental health services. The national community mental health service, which had a case-load of about 14,000 patients in 1990, relies on specially trained psychiatric nurse practitioners who provide crisis management, medication management, and supportive psychotheraphy; make home visits; and carry out treatment plans developed by the community psychiatrist. Community acceptance of mentally ill persons has been enhanced by public education programs and media coverage of advances in treatment (AU)

The effect of district psychiatric nursing science on admissions to the psychiatric hospital, Barbados - abstract

A prospective analysis of re-admissions to the Psychiatric Hospital, Barbados, conducted in 1990 by the author, revealed that the re-admission rate of patients registered with the District Psychiatric Nursing Services (DPNS) was substantially lower than the re-admission rate from the Outpatient Department (OPD) of the hospital and other services. It was proposed that expansion of the DPNS, especially to include the urban parishes (which contributed over 60 percent of the admissions), would significantly reduce the number of re-admissions. In 1991, the DPNS was extended to include to the urban parish of St. Michael and later the entire island. This study analyses the effects of the DPNS on admissions to the Psychiatric Hospital. It was found that for the first time in 16 years, instead of a rise in admissions, there was a 19 percent reduction in re-admissions during the years 1991 and 1992. In addition there was a 24 percent reduction in first admissions during the same period. The annual re-admission rate from the DPNS was 10 percent while in the case of OPD it was 65 percent (Xý=172.99, df=1, p<0.001). The DPNS at present provides highly specialized care for over 1308 outpatients while 1408 patients are manaaged by the OPD and all other services of the hospital. The extra cost incurred in the expansion of DPNS was BD$60,036.00 while the average cost for hospitalization of these patients for 3 weeks would have been BD$501, 765.00. The total annual cost of fullt expanded DPNS is BD$418,535.52 p.a. Thus the DPNS is not only responsible for reducing admissions and reducing patient morbidity, but also highly cost-effective (AU)

Validity of judgements of dangerousness among psychiatric outpatients in Grenada - abstract

Fifty-six patients in Grenada, identified by community mental health workers as hostile and threatening to them and refusing follow-up treatment, were studied for their degree of dangerousness by chart review and compared to a matched group of patients. Patients identified as dangerous were found to be more often young adult males, in the age group 20 - 35 years, single, abusing marijuana, alcohol or cocaine and with limited or no family support. These patients also had more admissions than the control group and had a background of repetitive violence in the community and in hospital, with multiple admissions to prison. They also were more often diagnosed as having personality disorder as compared to the control group. The finding of increased violence in the community associated with this group of patients validates the community mental health workers' perception of dangerousness and suggests the need for new out-patient commitment laws aimed at preventing non-compliance (AU)

Factors affecting compliance with depot injection treatment in the community

This study investigated aspects of the community psychiatric care of psychotic patients living in inner city areas, and especially those of Afro-Caribbean ethnicity. Ethnicity was not found to be a major factor affecting compliance with depot injections. More important were variables such as time since first treatment and sex. Defaulters from treatment were more likely to be subsequently admitted to hospital. (AU)

Feasibility of integrating community psychiatric services into primary health care facilities in Belize: a preliminary report

Paper states that the inception of a new Psychiatric Nurse Practitioner's Programme at the Belize School of Nursing in 1990 signalled the phasing out of the existing outreach program to rural districts. In its place would be a community-based psychiatric service headed by Psychiatric Nurse Practitioners deployed to district work stations. This study aimed at exploring the readiness of members of the health services previously involved to accept the impending change in psychiatric service delivery and to assess the extent of integration of community mental health at this time. In August of 1991, a self-administered questionnaire was issued to psychiatric service delivery personnel, both form primary and secondary care, and structured interviews were carried out with senior administrators in Belize. The results indicate a high level of basic training and a notable degree of integration already existing within the system. The vast majority of primary and secondary care respondents appeared willing to accept the new category of worker into the system, and both groups were also willing to participate in routine care of the mentally ill, especially if trained to do so. The administrators' responses hinted at a lack of cohesiveness among this group regarding achievement of policy objectives. In view of these findings, a forum for review of and forward planning for the psychiatric services in Belize would be welcome at this time(AU)

Ministry of Health: management review

Presents a review of five areas of the health services infrastructure, viz. General Hospital, Richmond Hill institutions, Princess Alice Hospital. Princess Royal Hospital and community health services. Details of the organizational structure and proposals for improved administrative practices and working conditions are given. Includes statistical data on medical, nursing and administrative personnel

Community mental health care in Grenada

In Grenada, community mental health (CMH) care as an essential element of comprehensive primary health care goes beyond the boundaries of the psychiatric hospital and interfaces with the communities it serves. The boundries between these two services however remain flexible and there often exists an interdependent relationship, with each acknowledging and utilizing the specific services provided by the other. This collaboration has been greatly facilitated by the fact that one administrative body is in charge of the entire mental health system throughout Grenada. (AU)

Characteristics of a rural area community mental health programme County Caroni

The paper describes characteristics and trends in a rural area Community Mental Health programme. Research done by the mental health team supports some of the previously held notions on alcoholism and dispels some myths about parasuicide and suicide. Education at all levels continues to be an important preventative measure in the fight against drug abuse. The effort to set up an Alcohol and Referral Center is partly thwarted by poor community resources. The mental health team has had to enlist the support of service organisations in their educationl programmes. More work needs to be done in the area of psychogeriatrics, rehabilitation and family life. The need for closer links between governmental agencies and the community is emphasized. (AU)