"Community Psychiatry" has had (and continues to have) many meanings, depending on whom you talk to, including:
- care for the uninsured/underinsured, in all its forms
- outpatient psychiatry
- government (usually city or county) run clinics
- clinics with multiple levels of care and case managers to help the most needy navigate the system successfully
What follows is a very long-winded answer to the question. Feel free to "Abandon Ship!" now.
However, I believe the term originated as an alternative to institutionally-based (typically large state hospitals) mental health care, where patients were often held for weeks to decades. Basically, there were often only two levels of care: private practice psychiatrists and large (enormous, often small cities really) hospitals. When the first significantly effective psychiatric medications were deployed (mostly 1950's), a large number of the institutionalized patients improved enough that it was possible to think about letting them live outside the hospitals.
With the 1960's generally increased interest in individuality and decreased interest in conformity. During this time, not-for-profit and gov't sponsored mental health centers opened up, staffed by crop of baby-boomer psychologists, social workers, and other mental health professionals. These clinics focused largely on assisting people with managing the difficulties of "normal" life (death of a loved one, divorce, couples' therapy, etc) and they were often resistant to, or directly hostile to, any "medical model" (especially medication) treatments. The term "mental health" was intended to avoid focusing on pathology and "medicalization." When they happened across someone with severely psychotic illness (esp. those with dangerous behaviors), those patient were typically referred to other entities (often the State Hospitals). These Mental Health clinics largely wanted nothing to do with people who had graduated medical school (unless they were of the ilk that denounced their medical training entirely) and psychiatrists interested in treating patients with severe or dangerous psychotic symptoms didn't seem interested in the MH clinics. At this time, Public Health depts were primarily focused on issues of sanitation and infectious diseases like TB and STD's - and did not provide much if any of what we now think of as Primary Care. The vast majority of private practice physicians (non-psychiatric) did not treat psychiatric disorders, so referred mild-moderate illness to non-psychiatrist MH practitioners (private or public), private practice psychiatrists, or State Hospitals. So gov't sponsored MH clinics were not a part of the Public Health system and the Public Health doctors, nurses, etc. were mostly perfectly happy to not have to deal with mental health whatsoever. As a result, public Mental Health grew up completely apart from the rest of the Public Health system - and we see that separation continued today in nearly every county across the nation.
In the 1970's, there was a big push to de-institutionalize State Hospital patients who were stable, both because of cost to the states and because of basic human dignity issues. The principle of only using the Least Restrictive treatments possible was pushed. In order to treat these patients in the "Community," programs for outpt psychiatric treatment, housing assistance and supervision, activities and training and supported employment were all planned and developed for the goal of assisting these patients to live in the community. Two huge things were forgotten:
A) Since there were few models for this, no one knew which programs would actually benefit patients and/or the community. All too often, the decisions about which kind of programs would be provided for which patients turned out to be based on assumptions about, "Well, this is obviously the right thing to do." There was insufficient thought about the "science" (observation, hypothesis, deciding an outcome to measure, testing, assessment, repeat) of this endeavor and so there were very few programs that kept records of the outcomes they were meant to influence. Let's face it, this was a time when more and more of American culture was based on, "If it feels good (or "right"), do it."
B) The funding for many of the programs was incomplete or non-existent, often with the promise of complete funding later. Very commonly, the treatment, housing, feeding of these patients formerly provided by the State was now left up to the counties or towns without any clear funding streams for doing that.
As a result, many of the programs changed, withered, or were simply never implemented at all. The joke in California is that Governor Ronald Reagan closed 50% of the State Hospital beds and therefore declared a 50% reduction in mental illness, so decided funding for Mental Health should be cut by 50%.
And so Community Psychiatry struggles to this day to define itself, decide what it wants to accomplish, and (in the past 10 years) squirms under ever-decreasing budgets while being saddled with more and more mandates about the details of services that will be provided and more community demands to keep the "normal" citizens safe from "crazy" people because "you never know what they might do," despite all the evidence that the vast majority of the risk of violence comes from family or friends, or from use/selling of alcohol and illicit drugs.
I believe we are slowly moving toward a true integration with the rest of medicine, as evidenced by the increasing frequency of psychiatry/MH clinics located within ambulatory medicine clinic buildings. It seems this trend is actually more rapid in rural settings. More evidence is coming in about the utility of such integration. Just a few days ago, I read the Journal Watch summary of research demonstrating the utility of Case Managers helping psychiatric patients navigate the Primary Care medical system.
As an example of the progress toward medical/community psychiatry integration, in my residency graduating class, the resident who shared the annual award for Commitment to Community Psychiatry through work/advocacy at various homeless MH clinics was the same one who won the award for outstanding resident in the Psychiatry / Primary Care Clinic where VA patients with severe and persistent mental illness had their psychiatric and general medical needs provided in the very same clinic.
