Mental health in primary care gap: now is the time to act

Since the 1978 Alma-Ata Declaration,¹ the world has seen a gradual transformation of healthcare delivery, with an increasing emphasis on primary care. The Alma Ata principles proposed that primary care would be the main vehicle to address healthcare problems in the community by providing preventative, promotive, curative and rehabilitative services and by reflecting the economic and social values of the country and community. These principles promote a patient-centred holistic approach to healthcare delivery, which includes proper nutrition, an adequate supply of safe water, basic sanitation, maternal and child care including family planning, immunisation, control of endemic diseases, health education and appropriate treatment for common diseases and injuries.

As the Alma-Ata Declaration was non-prescriptive it allowed for national interpretation. This meant that optimal benefits were not always achieved. The World Health Organization World Health Report 2008: primary health care – now more than ever re-focused on the core values of primary care and emphasised the need for the renewal of primary care.² The 2009 62nd World Health Assembly urged all member states to commit to the values of the Alma-Ata, by strengthening their healthcare systems and improving their primary care.³ It recommended acceleration towards universal access to a comprehensive effective primary care, putting people at the centre of all health programmes.

Mental health is an important element of primary care, yet 30% of countries do not have a budget for mental health. Of those countries that do have a designated budget, 21% spend less than 1% of their total health budget on mental health,⁴ and existing mental health budgets are often directed towards mental health secondary and tertiary care and often associated with a disproportionate use of old-style psychiatric institutions.⁵

Governments need to put in place health policies and laws that promote access to good-quality mental health services and emphasise the integration of mental health into primary care. They need to invest human and financial resources to ensure their implementation on the ground. The role of mental health advocacy needs to be recognised, so that services have the benefit of the point of view of those to whom they are most relevant – the service users.

Between 75% and 85% of people with a severe mental health condition in low- and middle-income countries and between 35% and 50% in high-income countries are not able to access the treatment that they need,⁵ and the stigma attached to mental illness is still one of the main obstacles affecting access to mental health care.^6,7 The stigma of mental illness affects those who suffer from mental illness and their families across generations, it affects the provision of psychotropic medication and other treatments, and it makes communities and policy makers view people with mental illness in low regard and leads to reluctance in allocating resources to mental healthcare delivery.

Poor access is also related to the increasing specialisation of healthcare providers and the narrow focus of single disease control programmes. This discourages a holistic approach to the individual and family, and does not appreciate the need for continuity in care. Health services for poor and marginalized groups are often episodic and severely under-resourced and, when development aid is provided to nations, resource allocation often clusters around curative services at great cost, neglecting the potential of primary prevention and health promotion.²

People who suffer from mental health problems also have higher mortality rates from other chronic health conditions when compared with the general population, as a result of the co-morbid physical health problems associated with mental health conditions compounded by the lack of appropriate access to health care. This is significant as mental, neurological, and substance use (MNS) disorders are prevalent in all regions of the world and contribute to 14% of the global burden of disease measured in disability-adjusted life years (DALYs).⁴

The complex relationship between access to mental health and physical health services has been addressed by the World Organization of Family Doctors (Wonca) in collaboration with the World Health Organization (WHO). A joint publication, Integrating Mental Health Into Primary Care: a global perspective, examined the global mental health landscape since the 1978 Alma-Ata Declaration and described the rationale for the integration of mental health interventions in primary care and emphasised that, as all mental health skills and competencies cannot be possessed by a single individual or unit, mental health is best delivered within a pyramid of care where primary care works as a conduit between informal community care and self-care and specialist mental health facilities and services.⁸

The evidence is that that the majority of patients with mental health problems, perhaps 80% or more, receive the bulk of their formal care in primary care settings. Self-care and advocacy are integral to every level of care and are as important as biopsychosocial interventions. Self-care and advocacy are cost-effective, reduce the number of contacts with health services, and should routinely be part of the service specification when services are being commissioned and procured. Mental health advocacy empowers the service user and provides a voice to express their views and defend their rights. Advocacy leads to improved self-esteem, increased independence, improved wellbeing and enhanced social support and coping mechanisms.⁹

The time for mental health in primary care has come

The 2009 World Mental Health Day global awareness campaign will focus on Mental Health in Primary Care: enhancing treatment and promoting mental health.¹⁰ This year's theme will address the continuing need to ‘make mental health issues a global priority’, and will stress the all-too-often neglected fact that mental health is an integral element of every individual's overall health and wellbeing. The campaign theme is intended to draw worldwide attention to the growing body of information and knowledge focusing on the integration of mental health in primary health care. Materials prepared for the campaign will assist grassroots patient/consumer, family member/caregiver, and advocacy organisations around the world to plan their local and national World Mental Health Day activities for 10 October.

The release, in September 2008, of Integrating Mental Health into Primary Care: a global perspective by WHO and Wonca signalled a major step in fostering a global effort to integrate mental health into primary care.

World Mental Health Day 2009 will highlight the opportunities and the challenges that integrating mental health services into the primary healthcare delivery system will present for people living with mental disorders and poor mental health, to their families and caregivers – and to healthcare professionals.

Advocates, families, professionals and policymakers across the global mental health sector know well that this current movement to improve the way in which mental health services are delivered is not the first such reform effort. Lessons learned from the past tell us that achieving parity in how mental health services are addressed in countries around the world is not an easy struggle. The effective integration of mental health into primary care at a level of priority appropriate to the documented burden of care of mental illnesses will be a major undertaking in a time of global economic and social difficulty.

The engagement of the ‘end users’ of mental health services, their families who often carry much of the responsibility for helping people living with mental illnesses to manage in the community, and the advocates who attempt to influence mental health policies, is critical during this time of change, reform, and limited resources. Several primary advocacy concerns that will have to be addressed as mental health services are integrated into primary care, including:

• the danger that adequate and effective diagnosis, treatment and recovery of people living with mental illnesses will not receive a parity level priority within the general and primary healthcare system

• the potential that primary healthcare workers in all disciplines will not receive adequate training and education necessary to effectively diagnose and treat people with mental health problems, especially the more serious disorders such as depression and schizophrenia

• the complexities of providing culturally competent mental health services to ethnic minorities and immigrant groups in increasingly multicultural communities and service settings

• probably the greatest challenge of all, the absence of trained primary and mental healthcare professionals in low-income countries and rural communities throughout the world.

Each of these advocacy concerns is significant in its own right. Together, they offer potentially major public policy and service delivery barriers to effectively integrating mental health services into the primary healthcare systems of countries. All will require well-planned and united advocacy on the part of all sectors of the mental health community if appropriate, accessible, and affordable mental health services are to be available to those who need them in the years ahead.

World Mental Health Day: a call to action for citizens and society

This year's World Mental Health Day call to action urges individuals, groups and governments to demand that we make our contribution to raising awareness of primary care mental health by:

• demanding that mental health is an essential part of primary care and family medicine, and that mental health should be included in all primary care services

• specifying that mental health is a key component of all primary care health services when these are commissioned and procured

• empowering individuals and mental health service users through the adequate recognition and resourcing of self-care and advocacy

• recognising care in the least restrictive environment and the role of family and community support as the first principle of all mental health interventions and treatment

• acknowledging that psychological, social and environmental interventions and resources are essential components of mental health for all, and access should be promoted for all

• ensuring that mental health training is facilitated and made available to all who work within primary care

• guaranteeing the availability of essential pharmacological therapy for those mental health service users who truly require it

• demanding an end to mental health stigma and discrimination, and monitoring and protecting the human rights of all people at all times

• facilitating the provision and support of specialist services for those whose needs cannot be met in primary care alone

• guaranteeing continuity of care for those with mental health difficulties, through primary care.¹⁰

We are keen to know what you are doing and what you have done. If you would like to share your local innovations with others please send your contributions to wonca.wmhd.2009@googlemail.com.

A positive experience of first contact with primary care practitioners can shape how mental health service users and their families perceive the mental health system. Primary care practitioners should not only see themselves as a first contact with services but also as ambassadors and advocates for the system as a whole. By working together we can all do our bit to narrow the mental health gap and improve mental health outcomes for the citizens of the world.