Primary care mental health and Alma-Ata: from evidence to action

The Alma-Ata Declaration of 1978 has been instrumental in primary care development worldwide.¹ The principles defined were for primary care to address health problems in the community, providing preventive, promotive, curative and rehabilitative services reflecting the economic situation and the social values of the country and its communities. Primary care was noted to be especially important for low-income countries. Its essential elements were the promotion of proper nutrition and adequate supply of safe water, basic sanitation, maternal and child care including family planning, immunisation, control of endemic disease, health education and appropriate treatment for common diseases and injuries. Because of administrative reasons, mental health was not mentioned in the Alma-Ata declaration. While the declaration did not include mental health the Alma-Ata official conference report included the promotion of mental health as one of the essential elements of primary health care. Could this account for the slow pace of the integration of mental health elements into primary care worldwide?

That the importance of mental health problems as one of the key health issues, in its own right, is well known. The World Health Organization predicted that in 2020 depression would be the second most important cause of disability after ischaemic heart disease.² The story is no different for other disorders often seen in primary care (such as anxiety), as many studies worldwide have shown a high prevalence of such conditions.^3–5 There are many reasons why treatment of mental disorders in primary care is the preferred treatment option for patients who suffer from these disorders. They include easier access, lower cost, issues associated with stigma, and cultural acceptability.^6,7 There is also evidence that mental health care can be provided in primary care in those low- and middle-income countries that have supported the development of primary care.⁸

Unfortunately, there is still a generally held belief that primary healthcare is a ‘solution’ for the poor, and not for the rich; therefore a lot of high-income countries prefer a specialist-dominated mental health service regardless of the evidence that primary care is a solution both for high- and low-income economies.⁹

Although primary care has been re-affirmed as the first level of contact,¹⁰ there are still doubts about the capacity of primary care physicians to detect common mental health disorders. This belief is often supported by reports from secondary and tertiary care services, which purports to show that primary care physicians are unable to make an early diagnosis and to provide treatment to people with mental disorders, mainly because of the shorter time for consultations that is available in general practice. Primary care physicians however, seem to operate satisfactorily after educational intervention programmes, even in countries with limited primary care capacity.¹¹ A major international collaborative study that explored the recognition and treatment of mental disorders in 15 countries demonstrated that the prevalence of mental disorders is high in the primary healthcare settings in all of the countries, despite their socio-economic and cultural difference, and that primary care physicians did not differ much in their capacity to recognise mental illness.¹²

A significant benefit that delivering mental health services in primary care can provide is that in instances where a mental health condition and a physical health problem co-exist, both can be treated simultaneously, and that doing so improves the outcome of both conditions. Thus, for example, in people with diabetes, depression is two to three times more prevalent than in people without diabetes; and the presence of depression increases the use of healthcare resources, as well as the self-perceived burden of the disorder. Treating the mental health problem does not only reduce the severity of the depression, but also improves the self-perception of the person who has the disease. Similar associations exist with ischaemic heart disease and depression, neurological conditions including stroke and depression, and with chronic obstructive pulmonary disease and anxiety disorders.¹³

When there are significant underlying mental health problems, people frequently present to their primary care physician with physical symptoms. This type of behaviour is common, and can account for up to 20% of primary care consultations. The consequence is that there are many referrals to secondary care specialists for investigation of symptoms that are caused by an underlying mental health problem rather than by a physical illness. It is primary care physicians who are best placed to identify these difficult cases, and to be able to offer the wide range of generalist skills and interventions that people need.

Primary health care is not only the first level of contact with individuals, but also the first level of contact for ‘the family and community … bringing health care as close as possible to where people live and work’.¹ Although the Alma-Ata declaration pointed out that primary health care among others ‘… should be sustained by integrated, functional and mutually supportive systems’, there is evidence that this goal has not yet been achieved. Complexity and fragmentation characterise the current healthcare systems across the world,¹⁴ and this is more visible in countries where primary care is less developed. The same also appears to be true in countries with strong capacity and resources, where GPs report a lack of services to refer to among the main obstacles to the provision of effective care to people with depression.¹⁵ The evidence so far tends to suggest that current primary care mental health delivery models worldwide are inadequate and inefficient across the spectrum of wealth.

A British study expressed concern about the fact that GPs and primary care physicians make a diagnosis and arrive at a decision about a treatment, influenced mainly by the severity of the symptoms and less by the recognition of social and environmental stressors.¹⁶ Treatment with psychotropic medication alone is unlikely to improve overall mental health. However, drug utilisation has doubled, and the majority of research on mental health problems has focused on pharmacological interventions, especially for common mental health problems. The increase in drug utilisation has occurred despite the fact that the overall prevalence of neurotic and psychotic disorder hardly changed from 1993 to 2000.¹⁷ Alternative models of care are needed for people with mental health problems that do not depend solely on pharmacological interventions, and do not arbitrarily divide healthcare provision into ‘mental health’ and ‘physical health’ services.

Although there is evidence that primary care is an adequate answer to most mental health problems, little is known about how it actually works. Research paradigms used in secondary and tertiary care do not give adequate answers to this question. More research should be done on the nature of primary care mental health services and the effectiveness of primary care approaches to mental health problems. Research should address not only pharmacological treatment options, but also other approaches to treatment, and should receive support from international agencies. In this new millennium the World Health Organization (WHO), the World Organization of Family Doctors (Wonca), the World Psychiatric Association (WPA), the many regional organisations such as the West African College of Physicians (WACP) and non-governmental organisations, need to work with governments with an interest in primary care mental health need, and progress beyond the rhetoric in order to deliver on the primary care mental health agenda in a practical way. In line with this, Wonca and WHO have formally launched a joint publication, Integrating Mental Health into Primary Care: a global perspective.¹⁸