This article reviews the recent developments in community mental health services, placing them in the context of the overall health delivery system in the country, and outlines the increasing contributions from social welfare organisations. Although the range of service components has grown considerably, improvements can still be made with regard to the cost-effectiveness and accessibility of psychiatric care to the community. Possible areas of collaboration between different service providers are discussed as a means to improve service delivery and to address the existing service gaps.
Key words: Community mental health services, Community psychiatry, Delivery of healthcare, integrated
Mental disorders impose a significant public health burden. Mental health problems such as mood disorders, mental retardation, epilepsy, dementia, and schizophrenia are among the top 10 leading causes of disability listed in the World Health Report. (1) Using the disability-adjusted life-years as a measurement tool, mental disorders have been estimated to constitute 11.6% of the total global burden of disease, and this figure is expected to increase further by the year 2020. (2) Although mental health has been given increasing importance in the international health agenda in recent years, providing comprehensive psychiatric services is still a low priority in many countries. (3,4) The allocation of additional resources is required to effectively deal with this growing health problem.
Drastic changes have been observed in the provision and delivery of mental health services over the past 50 years. Since the 1950s, due to an increased focus on the human rights of individuals with mental disorders, their long-term placement in mental asylums, many of which provided poor living conditions, was considered less than ideal. The development of new and effective medications has enabled patients with severe mental illness to live safely within the community. The move towards the deinstitutionalisation of state mental hospital patients was emphasised in many developed countries, and most of the large state mental hospitals were either downsized or closed. (5) However, deinstitutionalisation was associated with certain problems or negative social effects, and critics had highlighted the increased rates of defaulting treatment, illness relapses, forensic offences, and homelessness as undesirable consequences. Most patients had returned to the community without any preparation and social support, and therefore faced many difficulties coping in the new environment.
Community-based mental health services were developed to address these needs. (6) These services aim to provide effective mental health treatment and care to individuals with mental illnesses who live independently in the community of their choice. Comprehensive treatment in the community requires an 'array of therapeutic and supportive programmes designed to meet the needs of all patients and to meet the needs of a single patient at different times during the course of his illness'. (7) The United States was among the first countries to develop such services during the 1950s; the services included outpatient clinics, (8) halfway houses, (9) social clubs for 'ex-patients', (10) and visitation by professional teams. (11) Since then, the range of service components has considerably increased and improved. The current service components range from the generic to specialist community mental health teams, various types of supported housing and residential care facilities, crisis intervention and family care services, to vocational and social rehabilitation programmes. The move from hospital-focused care to community care has also been shown to be economically beneficial. (12,13)
The process of deinstitutionalisation has progressed more cautiously in Singapore. However, there is a definite move towards the management of patients with mental disorders within the community to improve their quality of life and reduce stigma associated with seeking treatment in a mental hospital. …