Embrace the community mental-health approach

Dr Clayton A. Sewell, Contributor

The recent controversy regarding the operations of the island's mental hospital should serve as a stimulus for Jamaica to consider other models of mental health care. The model to be adopted should be in keeping with the worldwide trend of expanding community mental-health services. Large mental institutions are considered outdated and outmoded and are seen as human warehouses.

In 2009, The Pan American Health Organisation urged member states, including Jamaica, to "continue activities to eliminate the old psychiatric hospital-centred model" and to strengthen community mental-health services. The recent Panama Consensus of October 2010 reiterated the need to strengthen the community mental health-care model in every country in Latin America and the Caribbean to ensure eradication of the insane asylum system in the coming decade. Belize has been applauded as the first country in the region that has successfully closed its mental hospital.

In the 1970s, Jamaica was able to reduce the population of the mental hospital from 3,000 to 1,500 and today the population of the mental hospital stands at 850. At the same time, we developed community mental-health services to the extent that, today, the majority of persons living with mental disorders are treated in their local communities and may access mental-health services at their local health centre and hospital. The recommendation to expand the community mental-health services is, therefore, not a new one but it is a call to provide a more comprehensive range of services at the community level, to facilitate quicker response to mental health crises in the community and improved services for children and adolescents.

Human-rights concerns

Many persons are held indefinitely in mental hospitals without opportunities to appeal this decision. This is a contravention of fundamental human rights. This raises serious implications as, increasingly, patients have started to challenge their forced confinement in local and international courts. This could have grave financial implications for Jamaica, as we have had cases in which the local courts have made awards to persons with mental illness.

Inefficient

Large mental hospitals are notoriously inefficient. In the case of the Bellevue Hospital, it requires approximately $1.1 billion per annum for it to operate in its current state. That is approximately $120,000 per patient per month. Many nursing homes and mental-health group homes cost significantly less. Roughly two-thirds of the population of the Bellevue Hospital patients are long-stay patients of advanced age who are quite similar to those being managed at the Golden Age Home. At the Golden Age Home it costs an estimated $140 million per year to operate the facility which accommodates about 440 elderly persons. Other models of care, such as the community group home model of managing the chronically mentally ill, have been estimated to cost $30,000 per month. Many effective and efficient community-based services have also been noted elsewhere in the world. The international consensus now is that managing the mentally ill in smaller facilities, closer to their place of origin is the most appropriate and humane approach.

The time is now for us to all reflect on the changes still needed in mental health care, strengthen what has been accomplished, and engage without delay in what we have not yet achieved. The time has come for the community-based model of care to be wholly adopted by Jamaica. This could result in significant savings to the taxpayer.

Dr Clayton A. Sewell is consultant forensic psychiatrist at the University Hospital of the West Indies. Feedback may be sent to columns@gleanerjm.com.