The Roles of Hospitals in Strengthening Mental Health Services in Primary Care in Low- and Middle-Income Countries: Reflections From the Philippines

Dear Editor,

In a recent article, Do et al highlighted the need to screen and assess older people living in rural areas. ¹ However, they also emphasized that screening in rural areas may be challenging in low- and middle-income countries (LMICs). ¹ This problem may stem from their severe lack of mental health care human resources, inadequate psychiatric hospital beds, and limited mental health services. ¹ In this paper, I argue and underscore the possible roles of hospitals in strengthening mental health services in primary care that can be considered in LMICs to expand mental health services to rural areas. I utilize the framework of hospital roles in primary care by Freijser et al, ² which includes direct primary care service delivery, improving the supply of frontline primary care services, integrating different levels of health care, and adopting a population-health focus. Finally, I situate my arguments based on another LMICs with similar conditions, the Philippines.

In the Philippines, most mental healthcare is provided in hospitals since community-based services are underdeveloped and suffer from a severe shortage of mental health specialists. ³ It only has about 0.52 psychiatrists, 0.07 psychologists, and 0.49 mental health nurses per 100,000 individuals, who are unequally distributed.^2,3 For instance, the majority of psychiatrists are located in Metro Manila. ³ Thus, there is a need to strengthen mental health services in primary care since there is a limited number of specialists and underdeveloped community-based services. Toward this endeavor, hospitals can take part in strengthening mental healthcare services in primary care.

First, hospitals can provide direct care to people suffering from mental disorders by conducting community-based programs expanding from mental health promotion to assessment and management. ² For instance, hospitals with psychiatry residency programs can set up community-based psychiatry rotations at primary care centers in rural areas to assist primary physicians in assessing and managing psychiatric patients. They can also conduct mental health promotion and education activities. Moreover, they can leverage the country’s vast internet users by offering these services through social media and other online platforms. ⁴

Second, hospitals can help supply frontline primary care services. ² For example, psychiatrists and other mental health professionals can institute training programs for primary care providers in rural localities in assessing and managing common mental disorders found in Philippine community settings, such as Schizophrenia. For instance, the WHO Mental Health Gap Action Programme (mHGAP) intervention guide, an evidence-based manual, can be implemented by hospital psychiatrists in training primary care physicians. ⁵ Further, supervision and training may be done through blended learning modalities.

Lastly, hospitals can promote continuity of care across the different levels of healthcare and population health by integrating their follow-up consultations and management with primary care services. ² For instance, long-acting injectable medications may be administered in primary care settings. Hospital and primary care electronic charts can also be integrated to provide seamless access to medical history and management. In addition, collaborative research between primary care and hospital physicians can also be conducted to better understand and address patient needs in their community settings. Overall, mental healthcare for all, regardless of geography and economic development, can be better achieved by leveraging hospitals to support mental health services in primary care.