Integrating mental health into primary healthcare

Introduction

Health is now widely acknowledged as having both a physical and mental health dimension. Indeed, as far back as 1948, WHO's constitution recognised health as ‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’.¹ Despite this, many primary healthcare systems in countries around the world focus on physical care, failing to provide mental healthcare to their populations.

Mental disorders are extremely prevalent in all countries and are responsible for immense suffering, poor quality of life, increased mortality and staggering economic and social costs. As such they cannot continue to be ignored. Today, 30 years on from the adoption of the Alma Ata Declaration, as the world prepares to re-affirm primary healthcare as essential healthcare, universally accessible to individuals, an important opportunity presents itself to change this state of affairs.² Indeed, a fundamental shift needs to occur in healthcare paradigm, from one of human rights violations and poor health outcomes associated with care delivered through psychiatric institutions, to one which respects human rights and promotes good health outcomes and recovery through the delivery of mental healthcare in the primary health-care system.

While this editorial focuses on primary health-care, it is important to emphasise that mental healthcare delivered in this setting is much more likely to be effective and sustainable if complimented by a strong secondary level of care to which primary healthcare workers can turn to for referrals, as well as for support and supervision. Having in place strong informal community mental health services and support groups, run by NGOs and faith-based organisations can also compliment and strengthen the services provided through primary healthcare services.

Why integrate?

The benefits of integrating mental health into primary healthcare are significant. On the one hand, integration ensures that the population as a whole has access to the mental healthcare that they need early in the course of disorders and without disruption. On the other hand, when people receive treatment in primary healthcare facilities the likelihood of better health outcomes, and even full recovery, as well as maintained social integration is increased.

Better access to care

Primary healthcare is ‘the first level of contact of individuals, the family and community with the national health system’, the closest and easiest form of care available, located near to peoples' homes and communities.² In many countries however, psychiatric institutions are the only form of mental health-care available to the population. These institutions are often located in major towns and cities, a long way from where people live, and consequently many individuals fail to seek the care they need. In cases where people do seek treatment in psychiatric facilities, they often find themselves very isolated, having to live far away from their families, removed from their emotional and social support networks and no longer in a position to maintain their daily living activities and jobs, often compounding economic precariousness for the family as a whole. Mental healthcare, available in primary healthcare, means that people are able to access the treatment and care that they need near to their homes, and thus keep their families together, maintain their support systems, remain integrated and active in the community and continue to contribute to household productivity. Furthermore, because primary care facilities are in or near people's communities, many indirect health expenditures associated with seeking care further afield (e.g. transportation to facilities located in urban areas, loss of productivity related to the time spent in accompanying the patient to hospital, etc) are avoided, making primary healthcare the most affordable option both for patients, the community and the country.² In addition, in most countries, primary care services are either free or at least less expensive than secondary or tertiary care.

Because primary care services are not associated with any specific health condition, the fear of being stigmatised as ‘mad, bad and dangerous’ or marginalised from the community and discriminated against is reduced, making this level of care far more acceptable – and therefore accessible – for most service users and families. Mental health services in primary healthcare are also more acceptable because they reduce the risk of people being exposed to human rights violations often associated with psychiatric institutions.³

Thus, mental healthcare, delivered in primary healthcare settings is more accessible, affordable and acceptable for the population.

Better health outcomes

In terms of clinical outcomes it has been found that, for many mental disorders, primary healthcare can deliver good care and certainly better care than that provided in psychiatric hospitals. Indeed recent evidence indicates that mild, moderate and even severe depression can be effectively diagnosed and treated in primary care settings.^4,5

There are several reasons why treatment of mental disorders in primary healthcare services results in better health outcomes. One reason is that mental health is often co-morbid with many physical health problems such as cancer, HIV/AIDS, diabetes and tuberculosis, among others.⁶ The presence of substantial co-morbidity has serious implications for the identification, treatment and rehabilitation of affected individuals. By attending to the physical health needs of someone with a mental disorder, or alternatively, to the mental health needs of someone with a physical health problem, a primary care worker can provide treatment and care in a holistic manner that greatly increases the likelihood of a good health outcome.

Another reason for improved health outcomes is that primary care practitioners are in the unique position of providing care throughout people's life cycle, from birth until death. Treatment in the primary care setting allows for continuity of care beyond the mere ‘one off’ consultation and treatment (often resulting in poor adherence to treatment regimens) to ongoing treatment and follow up care for mental disorders. In addition, the fact that people needing care are able to continue living with their families, in their communities means they are more likely to be able to maintain strong links with society as well as with sectors that are important to mental health such as social welfare, education and labour, all of which is conducive to recovery.

WHO recommendations

Clearly the provision of effective mental healthcare at primary healthcare level is highly dependent on the pre-existence of a well-functioning primary care system. Sufficient resources (financial and human) are also a pre-requisite for effective mental health treatment at this level of care. In addition, WHO has a number of specific recommendations that are fundamental for undertaking successful integration of mental health into primary healthcare.

Policy, plans and laws

Health and mental health policies, plans and laws should all reinforce the development of a strong primary healthcare system as well as the integration of mental health within that system. Only with a formal commitment at the highest level of government can this undertaking really succeed. Mental health policies in particular can define the specific objectives to be strived for in integrating mental health, while plans can outline in detail the specific strategies and activities required for doing so.⁷ Mental health laws, in addition to providing a legal framework for enforcing policy objectives, can reinforce integration by legislating for parity between physical and mental healthcare and by introducing specific provisions promoting deinstitutionalisation and the provision of care in primary healthcare settings.^8,9

Human resource development and training

Integrating mental health services into primary healthcare can be an important solution to addressing human resource shortages to deliver mental health interventions. At same time there needs to be sufficient numbers of primary healthcare workers (including general practitioners, general nurses, mid-wives, nursing assistants and community health workers) with the requisite skills and competencies to identify mental disorders, provide basic medication and psychosocial interventions, undertake crisis interventions, refer to specialist mental health services where appropriate, and provide psycho-education and support to patients and their families.¹⁰

Mental health training should be included in the curriculum during undergraduate medical and para-medical studies and should be actively reinforced in the form of on-the-job training and supervision. Continued professional development (CPD) training courses of primary healthcare workers should also include a strong mental health component.

Supervision, support and referral

While primary care staff should be trained to identify, treat and manage the majority of cases of mental disorders, some more severe cases may need to be referred to specialists at the secondary level of care. An effective referral system between primary health-care and secondary mental health facilities is there fore a crucial component of mental healthcare delivery in primary healthcare.¹¹

Adequate supervision of primary care staff is another key issue for successful and sustainable integration. Mental health specialists (e.g. psychiatrists or mental health nurses) must be made available to primary care staff to give advice and guidance on the management and treatment of people with mental disorders.¹¹

It is important to highlight that the recommendations outlined above cannot be undertaken in a vacuum. Instead, they must occur within the context of a broader clinical, administrative and financial shift towards integration into primary healthcare. This means, for example, that financial and human resources need to be re-directed from tertiary care towards primary care and that psychotropic medicines should also be made available at primary healthcare level. In sum, though the delivery of mental health services in the primary care setting is cost effective, attention needs to be paid to ensuring that resources for mental health are re-directed appropriately and that the additional required resources are provided.

Joint WHO/WONCA report on integration

Against the backdrop of renewed international attention on primary healthcare and the upcoming 2008 World Health Report on the same topic, WHO and WONCA are developing a Report on Integrating Mental Health into Primary Health Care.

The report provides policy makers and planners of health services with the rationale and know-how for moving from an institutional model of mental healthcare to a more holistic, comprehensive integrated delivery system at the primary healthcare level. In addition, through a series of best practice case studies of long-standing and successful services from around the world, the report provides specific in formation, direction and recommendations for undertaking effective integration in a number of different country resources settings.

The institutional model is still the norm in most resource poor counties. By providing clear and comprehensive guidance on this issue it is hoped that more governments will integrate mental healthcare into primary care settings, thus promoting better access to mental healthcare, respect for human rights, and ultimately, better ‘physical’ and ‘mental’ health outcomes.

Biography

The authors are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.