More than half a century has passed since the first change in planning and providing mental health services from individual-based to the community-based approach. Consequently, Community-Based Mental Health Centers (CMHCs) were stablished in catchment areas for public access, cross-sectoral cooperation, and continuing provision of care services, with the aim of providing comprehensive mental health services. In Iran, first CMHC was established in 2010. Although there is an evidence of successful implementation of these programs in various countries (e.g. Canada, the United States, Australia, and Southeast Asia), mental health programs still need to be designed and implemented based on the needs of each community. The burden of mental disorders and their prevalence are important indicators for planning mental health services. The results of a study conducted in the Eastern Mediterranean region in 2013 showed that the burden of mental disorders increased by 10.8% from 1990 to 2013. The results of the 2015 Mental Health Survey in Iran reported the prevalence of mental disorders as 23.6%.
One of the most important indicators of the desirability of a service delivery system is the evaluation and use of its results in future planning. After several years of implementation, it is necessary to evaluate the achievements, opportunities and challenges to continuing the program. This study aims to evaluate the community-based mental health care program in Iran for its continuitation and improvement of its implementation.

This is a qualitative study that evaluates the performance of CMHCs in the two areas of participatory care and home visits. We conducted 36 individual interviews and 13 focus group discussions with the participation of project implementers at the Ministry of Health, psychiatrists in the CMHCs, psychologists and physicians collaborating with the project, patients using receiving services and their families. The CMHCs belonged to medical universities in Tehran (Iran University of Medical Sciences, Tehran University of Medical Sciences, and Shahid Beheshti University of Medical Sciences), Tabriz, Zanjan, Kerman and Yazd. Participants were selected by a purposive sampling method. According to the obtained concepts, new samples entered the study and this process continued until data saturation.
Data analysis was performed using qualitative content analysis method of Graneheim and Lundman (2004). Guidelines were designed for the interviews and group discussions to ensure that the researchers obtain same information, which included open-ended key questions focusing on the extent to which the objectives are achieved. If necessary, additional questions were added following the creation of categories. MAXQDA v.10 software was used to manage and organize the data.

The strengths of community-based mental health care program in Iran included: The transparency of the protocol, joining of physicians in private sectors to the public sector, change in the attitude of general physicians towards the treatment of mentally-ill patients, defining the role of Case Manager and adding it to the program, reducing the stigma of disease and making people more aware of mental illness, reduced recurrence and hospitalization of psychiatric patients and family satisfaction. The challenges in implementing and coordinating between the project components included: Lack of access to a regular list of physicians in the private sector, employment of general physicians in some areas such as beauty and slimming and establishing addiction treatment centers, lack of cooperation of some physicians due the project’s low income, delays in payment of salaries due to delay in budget payment by the universities and the centers’ financial problems, and the cultural differences of each region. The challenges related to the role of Case Manager included: Assigning multiple tasks without closing a contract, existence of no medical receptionist for some physicians, and the unwillingness of some physicians about giving the patients’ information to the receptionist. Another challenge was related to the paradoxical design of the continuation of the referral cycle from the physician to the psychiatrist (providing free services to the patients by the psychiatrist and unwillingness of patients to return to the physician). Some challenges were related to entering information in the registration system. A lot of time was needed to record information. There was no system guide, and no ability to receive reports. 

The evidence showed the community-based mental health care program’s success in the community and the satisfaction of service providers and recipients. The CMHCs facilitated the people’s access to mental health services and reduced the stigma of psychiatric diseases. This program, like other new programs, made a change in the system which required a lot of effort. A strength of this program was the use of capable staff. The role of all staff, especially psychologists and psychiatrists, was one of the most important factors in achieving the goals of the project, which raises hopes for the implementation of the program at the national level. Almost none of the CMHCs were satisfied with following the instructions and did their best to provide the service even more than the recommended level; in case of any problem, they attempted to solve the problem. These centers holded supervision meetings for the physicians and communicated with charity centers to provide services to the families of patients in their home. Patients quickly applied for additional services such as social works, occupational therapy, pediatric psychiatry, rehabilitation, and day care. Satisfaction of service recipients indicates the need to pay more attention to CMHCs and their empowerment, as well as the centers’ high capacity to continue to provide community-based mental health services. We recommend: 
Paying more attention to psychiaty and mental health educational programs in the general medicine curriculum;
Familiarizing the general physicians more with the community-based mental health services;
Providing public information about the services;
Providing public education and culturalization;
Partnership with other organizations;
Upgrading the information registration system;
Examining the existing ways to attract funds from other sources such :::::as char:::::ity organizationas and influential people;
Evaluation of physicians based on funcional indicators;
Strengthening internal monitoring and evaluation of the system and exchange the experiences between the centers. 

All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them. The study was apptoved by the Ethics Committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1398.865 ). 

This study received financial support from the Mental, Social and Addiction Health Office of the Ministry of Health and Medical Education.

Conceptualization, investigation, software, validation, formal analysis, investigation: All authors; Methodology: Morteza Naserbakht, Mozhgan Taban; Writing – original draft: Mozhgan Taban; Writing – review & editing: Morteza Naserbakht; Resources: Morteza Naserbakht, Mozhgan Taban, Mehri Gholami; Supervision: Morteza Naserbakht, Mozhgan Taban.

The authors declare no conflict of interest.

The authors would like to thank the the Mental, Social and Addiction Health Office of the Ministry of Health and Medical Education.
 

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