Integrating mental health into primary care in Sverdlovsk

Abstract

Introduction Mental disorders occur as frequently in Russia as elsewhere, but the common mental disorders, especially depression, have gone largely unrecognised and undiagnosed by policlinic staff and area doctors.

Methods This paper describes the impact and sustainability of a multi-component programme to facilitate the integration of mental health into primary care, by situation appraisal, policy dialogue, development of educational materials, provision of a training programme and the publication of standards and good practice guidelines to improve the primary care of mental disorders in the Sverdlovsk region of the Russian Federation.

Results The multi-component programme has resulted in sustainable training about common mental disorders, not only of family doctors but also of other cadres and levels of professionals, and it has been well integrated with Sverdlovsk's overall programme of health sector reforms.

Conclusion It is possible to facilitate the sustainable integration of mental health into primary care within the Russian context. While careful adaptation will be needed, the approach adopted here may also hold useful lessons for policy makers seeking to integrate mental health within primary care in other contexts and settings.

Introduction

In Russia, the transition to a market economy, which at times has been accompanied by severe economic problems, has been associated with a fall in life expectancy, triggering a longstanding health crisis.^1–5 Non-communicable diseases, including high rates of alcohol consumption, mental illness and suicide have been major contributors to this decline. In 2002 they were responsible for about 76% of all deaths in the Russian Federation; the highest excess mortality in the country has been due to intentional and unintentional injuries and suicide.⁶ At its peak in 1994, the suicide rate for Russian men aged between 50 and 54 was over six times that in the United States.⁷ Although suicide rates in the country have since fallen sharply, they remain among the highest in the world. In the World Health Organization (WHO) European region, after Lithuania and Kazhakstan, Russia still had the third highest mortality rate from suicide and self-inflicted injury in 2006.⁸ The economic costs of poor mental health are also substantial; while no specific estimates exist for Russia, studies elsewhere in Europe have conservatively estimated that these costs may account for as much as 4% of Gross Domestic Product (GDP).⁹ If replicated in Russia this equates to a cost to society of some $90 billion (PPP international dollars) in 2008.¹⁰

The Russian health system has long been dominated by hospitals, vertical service-delivery systems and a curative focus. In 1978 the former Soviet Union hosted the Alma Ata conference on Primary Health Care, which led to a major emphasis in many countries on strengthening primary care to deliver accessible community based care, and to act as a gatekeeper role to secondary care. But there was little space for primary care under the old Soviet system. Within the Russian Federation, primary care remained marginalised,¹¹ even after recognition of family medicine as a specialty by the Federal Ministry of Health in 1992.¹² It has remained poorly funded with much of the impetus for reform relying on support from international funding agencies.¹³

Moreover, mental health services are not well integrated with primary care, but instead have had a largely institutional focus,¹⁴ with an emphasis on psychosis and personality disorder rather than the common mental disorders, including depression and anxiety. There have been various efforts to strengthen primary care for general medical disorders in Russia,^15,16 but mental health has not been systematically included in training for primary care staff, who have traditionally seen their role as one of referral rather than treatment.¹⁷ One small qualitative study identified that family care practitioners receive little or no training in mental health, although they now recognise the importance of being able to identify and treat mental disorders.¹⁸ Barriers have included long-standing reliance on mental health specialists, together with the stigma associated with mental health problems, creating a situation in which both doctors and their patients avoided addressing mental health issues. Systematic approaches are needed to strengthen primary care to function well^12,19 and to contribute appropriately to addressing the mental health burden in Russia.^20–22

This paper therefore describes a multi-component primary care initiative designed to facilitate the integration of mental health into primary care in the Sverdlovsk oblast (administrative region), located in the Ural mountains of north central Russia. This initiative was undertaken as part of a wider multi-sectoral mental health reform project led by the Oblast Ministries of Health and of Social Protection, in partnership with the WHO Collaborating Centre at the Institute of Psychiatry and funded by the Department for International Development (DFID).¹⁷ The multi-component primary care initiative comprised (a) a detailed situation appraisal, (b) policy dialogues with oblast and federal bodies, (c) design and implementation of a training programme for primary care doctors, delivered by Russian teachers, (d) strengthening sustainability by adoption of the curricula by key bodies responsible for undergraduate and postgraduate training and continuing professional development (CPD), (e) development of an oblast standard on depression in response to a request by the oblast Deputy Health Minister, and (f) the adaptation and dissemination of the WHO Primary Care Guidelines for mental disorders.

Methods

Situation appraisal

The situation appraisal of the governance and delivery of primary care of mental disorders in Sverdlovsk was conducted by means of site visits, consultations and interviews with key stakeholders including officials, professionals, non-governmental organisations (NGOs), clients and their families. Information was also collected from a review of local data and relevant literature.

Policy dialogues

Meetings were held with the Sverdlovsk Ministry of Health and the Federal Ministry of Health to:

• establish whether there were any legal or other impediments to the integration of mental health activities into primary care

• design a training programme

• determine the potential role and positioning of standards and guidelines within the oblast health sector reform programme

• co-ordinate the production of an oblast standard on depression

• co-ordinate the adaptation and dissemination of an oblast adaptation of the WHO Primary Care Guidelines on mental disorders

• co-ordinate dialogue with the oblast educational institutions about curriculum

• consider levers for sustainability after the end of the project.

The primary care training programme

The training programme consisted of a five-day module of multi-method teaching (with an emphasis on practical skills acquisition), which covered depression, anxiety, substance abuse and other common problems. Teaching slides, role-plays and videos were adapted for the Russian context in dialogue with Russian partners, including the Chief Therapist of the oblast Ministry of Health, in discussion with the Department of Family Medicine and with the Federal government. The skills based teaching is based upon the World Psychiatric Association's training packages for primary care doctors, produced in English by LG and DG,^23–26 which were dubbed into Russian by Professor Nikolai Kornetov of Tomsk. These consist of videotaped consultations between real general practitioners (GPs) and role-play patients, and demonstrate particular mental health skills, with an accompanying commentary by a mental health professional. The tapes are accompanied by role-plays to enable doctors to practice the behaviours that have been modelled for them.

Courses were run to teach non-psychiatrists (family doctors, general physicians, cardiologists, gynaecologists etc.) how to recognise and treat depression. The original plan was to provide a skills-based training course, through which doctors could practice some of the essential skills that are needed in this work. However, during the first course it was found necessary to supplement this with didactic teaching, as our doctors knew very little about common mental disorders. Over the following three years the course has evolved to include both didactic and skills-based training on the assessment and management of unexplained somatic symptoms, of depression and of alcoholism. In the first year 46 doctors were trained, including two who were identified as suitable future trainers by virtue of their training expertise and position – one was Professor of Psychiatry in the Oblast Medical Academy, and had responsibility for teaching undergraduate medical students about psychiatry, and the other was a lecturer in the Department of Family Medicine, responsible for vocational training for general practitioners.

Emphasis was placed on intensive development of local lecturers, including those who could continue the training programme for family doctors as part of the oblast's wider programme of family doctor development, those who could incorporate the methods into undergraduate teaching and those who could incorporate the methods and content into specialist teaching. During later visits the English tutors (DG and LG) provided additional lectures on request, but mainly concentrated on giving feedback to the Russian teachers. In the third year the main Russian trainer (AZ) visited England and watched skills teaching of British GPs by role-play, after which the role-plays in Russia became better established. The depression attitude questionnaire was administered before and after training to sets of participants including area doctors, GP trainees and senior general medical academic staff.

Dissemination and sustainability

Curricula and teaching materials from the primary care training course were disseminated to university lecturers with responsibility for undergraduate and postgraduate training and CPD. An oblast standard on depression, the production of which was co-ordinated through project workshops and access to international evidence-based materials, was developed and disseminated. The WHO Guide to Mental Health in Primary Care, adapted for the UK,²⁷ was translated into Russian and distributed for consultation to health and social sector policy staff, universities, specialist teams and all primary care doctors and physicians attending for the training programme. Russian colleagues asked for additional material on substance abuse, obesity and child and adolescent disorders, which was provided from the UK second edition.²⁸ The preliminary adaptation for Russia of the WHO Primary Health Care (WHOPHC) guidelines was then discussed at a series of workshops with primary care doctors and other professionals, and held to be suitable for Sverdlovsk. A working group was set up to complete the final adaptation and the contextual sections were written by Sverdlovsk partners. Examples of comments received included the following from a hospital internist, policlinic doctor and area doctor respectively:

‘Very informative and accessible. Now my eyes are open I will treat patients as my relatives.’

‘The guidelines very accessible and good reading.’

‘I know a whole generation of patients. Different stages of drug addictions come to us first. The manual will help me handle patients.’

Results

Situation appraisal and policy dialogue

The Sverdlovsk oblast is similar in size to France, with an area of 194 300 km², and has a population of 4.44 million. It is sparsely populated, with 23.1% of the population residing in the six principal administrative cities within the oblast. The capital, Ekaterinburg, is the largest city with a resident population of approximately 1.29 million. Sverdlovsk is broadly representative of the economic development and health system structures found throughout the country. Physicians learn only briefly about depression as fifth year medical students, and no information about depression is given in the continuing education programmes for doctors.

The structure, staffing and functioning of primary care

In Russia, general primary care and specialist outpatient care are based together in policlinics, normally attached to general hospitals. Thus, the policlinics contain both generalist area doctors with responsibility for a catchment population, and specialist doctors. In isolated rural areas, where there are no policlinics, primary care is delivered by feldshers (health professionals with a three-year medical training). Policlinics are normally part of a hospital but nonetheless are the first point of contact between the area doctor and the patient, who may then be referred to a specialist within the policlinic or to an inpatient department within the hospital. Policlinics have treatment rooms where various primary care procedures as well as specialist procedures may be conducted. Overall, primary care is delivered by feldshers in rural areas and generalist area doctors, who each cover about 3000 to 4000 people, in urban areas. Policlinics normally did not previously have any psychiatrists, but some now do. In larger urban areas there are special psychiatric ‘polyclinics’, which work solely with mental disorders and do not see or treat common medical conditions. Thus, mental health is still a separate and isolated system within the health system.

Site visits to area doctors indicated that the most common reasons for consultation at primary care level included ischaemic heart disease, chronic lung disease, arteriosclerosis, psychosomatic problems and depression, although the area doctors undertake very little treatment of common mental disorders. In general, primary care in Russia is not working well, either in relation to severe mental illness or to non-psychotic disorders, because of the lack of: mental health in the training of primary care doctors; accessible good practice guidelines; and information systems which include common mental disorders. There is also a lack of clarity over whether non-psychiatric doctors are allowed to treat common mental disorders, including depression, and to prescribe antidepressants. Certainly, neither the feldshers, the area doctors nor the non-psychiatric specialists have hitherto been expected to treat common mental disorders. Rather, all mental disorders are expected to be diagnosed and treated by specialist services. The general presumption in the health and social protection sectors has been that all mental illness must treated by a psychiatrist and that legislation would be required before mental health care could be integrated into primary care. Indeed there is a common misperception, reported in an assessment of mental health services elsewhere in Russia,²⁹ that according to a Federal law of 1993 only psychiatrists (or a feldsher if no doctor is available) can diagnose or treat mental illness. However, the federal and oblast ministries are sure there is no such law, and agreed to our training of generalist doctors about depression as part of this project.

Governance issues

A number of policy and governance issues were found to be relevant to the facilitation of primary care of mental disorders, including the issues of governmental guarantees, standards, and the oblast formulary. The main current programme of health policy work being undertaken by the Sverdlovsk government is the implementation of the Federal programme of governmental guarantees, which sets the minimal volume of medical services which are provided free to the population. It provides for acute medical services to the population and also for planned treatment. It sets both federal standards and local norms per capita, and helps the oblast decide on its priorities.

Mental health is included in this work programme. A new trend in Russia has been to develop detailed clinical standards for health services, and the project facilitating the development of an oblast standard on depression was conceived in response to a direct request from the oblast Deputy Minister for Health. In addition, the deputy minister is undertaking a step-by-step reform of 87 polyclinics and outpatient services, and considered that the primary care component of our project could fit well with that reform. The Chief Therapist of Sverdlovsk is the senior doctor leading primary care in the oblast.

The deputy minister is responsible for the oblast formulary, which determines which medicines are available free to patients. This formulary is revised every three months. There is no difficulty in principle with the supply and distribution of psychotropic medicines to primary care in Sverdlovsk. The Ministry of Health requested the project's assistance in updating the oblast formulary, and saw the adaptation of the WHO primary care guidelines as a valuable adjunct to their health sector reforms. While there was a widespread view amongst health practitioners that treatment of depression in primary care was illegal, the oblast Ministry of Health has a legal department which monitors relevant federal laws and was able to confirm that there is nothing in law to say that antidepressants may not be prescribed in primary care, and this was also confirmed by the federal government. Improved access to treatment free at the point of use in primary care is important, given that previous research in St Petersburg indicated that access to treatment for depression was severely limited, with most individuals having to pay in order to obtain antidepressants. Out of pocket costs for these drugs were cited as a major barrier for up to 75% of individuals in that study.³⁰

Training for different cadres within the oblast

Medical students are trained in the Urals State Medical Academy (USMA) and other medical colleges in the oblast. The Oblast Medical College (OMC) trains other health professionals (nurses, feldshers, social workers, laboratory workers, midwives, dentists and stomatologists, massage specialists, nurse managers and teachers) and leads training, research, methodology and organisation in the oblast for these specialties. The OMC is involved in the federal reform process and in setting federal and state standards for education in nursing. Feldshers are the key human resource for rural primary care. They undergo a three-year training course which covers the recognition and management of symptoms and disorders and prikazi (regulations). Physicians in Russia learn only briefly about depression as fifth year medical students, and no information about depression is given in the continuing education programmes for doctors, including psychiatrists.

Training of primary healthcare staff

Over 300 GPs have now been trained in mental health for general practice using the training programme developed within the framework of this project and they actively use their knowledge and skills in practical work, detecting and treating psychosomatic disorders, including depression, at an early stage. The early courses have been evaluated and reported elsewhere.³¹ In addition, three further professors from the Department of Continuing Education and Professional Development have been trained as trainers for the course, making five professorial trainers in all. Since 2007, joint courses have been conducted for general practitioners and psychiatrists coming from the same districts (during courses of professional development for psychiatrists at the Chair of Psychiatry, Department of Continuing Education and Professional Development, USMA) to ensure collaboration between GPs and psychiatrists in the region. In addition, since 2007 Sverdlovsk psychiatrists have received two sessions of three hours each on the interactions between psychiatric services and general practice in treating patients with depression, anxiety and unexplained somatic symptoms. An advanced course of 144 hours, devoted to issues in mental health, has now been organised for primary care doctors, and 14 doctors have so far completed this.

Training specialists to support an enhanced role for primary care

The Oblast Medical Academy (OMA) runs the CPD curriculum for psychiatrists, and each psychiatrist has to attend once every five years. In 2003 the OMA took all the specialist psychiatrists from all the pilot sites for CPD that year, and used the translated project materials (WHOPHC, management texts etc.), the curriculum on diagnosis, and teaching materials on client needs to develop the CPD curriculum. Since then the OMA has delivered CPD based on the project materials to all psychiatrists in the oblast. There remains a need to focus more training on the community, and to give a higher profile to the role of the nurses and to multidisciplinary working. New approaches are needed on the use of medication, rehabilitation, diagnosis (with less use of the category of personality disorder and more diagnosis of depression), professional ethics and to the understanding of the potential role of NGOs. The revised CPD curriculum has enabled specialists to become more enthusiastic about the potential contributions of both the wider community and of primary care to mental health care.

Sustainability of project outcomes through integration of materials and methods into basic, post-basic and CPD training programmes

The integration of mental health into primary care in Sverdlovsk is now a key part of the chief therapist's work programme within the Ministry of Health. There are 267 general practices in Sverdlovsk, all of whose primary care doctors have now received the training course in mental health. Indeed, there is one municipality, Kusvha, with a population of 46 100 residents, which now has 20 general practices with another four to be opened shortly, meaning that all of the population will now have access to GPs trained in mental health. Three key trainers for non-psychiatric doctors are now operational, one in the Oblast Medical Hospital who runs courses for non-psychiatric hospital staff, one in the department of Family Medicine who runs courses for policlinic and area doctors in the oblast and one in the OMA who runs courses for policlinic doctors in the city of Ekaterinburg. The courses include role-plays, interactive teaching and the WHOPHC guidelines. An advanced course is now also being prepared.

The educational materials and training curriculum about common mental disorders including depression have been incorporated by the OMC into its curriculum for nurses and for feldshers at basic, post-basic and CPD levels; and by the OMA into its curriculum for medical students and for the specialist training and CPD of psychiatrists. The educational materials and curriculum are also being used by the Oblast Psychiatric Methodology Centre to support future workshops, and by the Urals State University Department of Psychology for trainee psychologists. The OMA has now introduced into the curriculum for medical students; the bio-psychosocial approach, social psychiatry, management of mental disorders in primary care and familiarity with the ICD10. They have also introduced into the training of interns much more attention to the common disorders of depression and psychosomatic disorder, dementia, alcoholism and drug abuse.

Teaching staff in the OMA now make systematic use of the new teaching practices of role-play, video and discussion, and of the WHOPHC guidelines and a translated book on the development of national mental health policy.³²

The oblast standard on depression has been printed and disseminated. The WHOPHC guidelines have been reprinted and disseminated both within Sverdlovsk and other oblasts. These materials are also used by the Oblast Mental Health Methodology Centre which organises consultancy and support for mental health services within the oblast in order to improve standards.

There have also been a number of broader benefits for primary care that go beyond mental health. The experience gained from the adult mental health project¹⁷ of establishing and evaluating pilot projects is now assisting the Ministry of Health in the establishment of a pilot project in primary care aimed at the prevention of non-communicable diseases. The networking experience derived from the adult mental health project has contributed to the establishment of a network of GPs in the region who are in regular contact with one another. By way of providing continuing education, the GPs hold a conference once a month on different topics, most recently on the mental health care needs of older people in primary care. Thus, the Mental Health Professional Development Unit of the USMA has established a regular relationship with primary care services, providing further evidence of sustainable impacts of the project.

Discussion

Despite the limitations of this project, which included the difficulty of working through interpreters and the limited resources available, this project has shown that over a relatively brief time span of three years it is possible to systematically initiate and support the integration of mental health into primary care in a region of Russia, through a multi-component programme of; situation appraisal, policy dialogue with oblast and federal bodies, development of educational materials, design and implementation of a training programme for primary care doctors, training Russian teachers to continue the courses in future, dissemination of curricula and the development of oblast standards and guidelines. It has also demonstrated that the integration of mental health into primary care, with its emphasis from the start on sustainability, has not only continued but expanded, using local resources, since the end of the bilateral aid project.

The beginning of the project coincided with the beginning of reforms for primary care in Sverdlovsk with the development of general practice. In 2003, nine general practices were set up in rural areas of the oblast; by 2005 the number of GPs in Sverdlovsk had grown to 46, and to over 300 by 2009. All these GPs have now been trained using the training programme developed within the framework of this project and they actively use their knowledge and skills in practical work, detecting and treating psychosomatic disorders, depression etc. at an early stage. Our project was therefore synergistic with the overarching Russian developments in primary care, as well as with WHO's long-standing goal of integration of mental health into primary care. More teachers have been trained, the teaching materials and methodology are firmly embedded in basic and post-basic training, as well as in CPD, and various courses are now on offer. Practice is reinforced by the dissemination of good practice guidelines and standards.

Sustainability was sought from the beginning of the project through dialogue with both the oblast and federal ministries, and through ensuring that curricula and training techniques were picked up by lecturers responsible for basic training of medical students, postgraduate training and specialist CPD programmes. Curriculum development for primary care is a key policy issue,³² and strength of Russian policy making is its emphasis on systematic implementation. This proved extremely helpful in supporting the future sustainability of project outcomes. External donors to Russia's health care system, including the World Bank and DFID, have also facilitated this process by encouraging the development of an increased emphasis on primary care and a shift of health care activity from specialist care to primary care. There may also be economic benefits associated with a more primary care driven approach to mental health in Russia, although careful evaluation is still required. Better management of common mental disorders within primary care may help avoid the need for potentially more expensive specialist care and reduce time out of normal daily role.

Conclusion

This multi-component primary care programme, undertaken as part of a wider mental health reform project in Sverdlovsk, has resulted in sustainable training about common mental disorders not only of family doctors, but also of other cadres and levels of professionals, and is well integrated with Sverdlovsk's overall programme of health sector reforms. It has shown that it is possible to facilitate sustainable integration of mental health into primary care within the Russian context. The process can also help ensure that formularies which determine which treatments are provided free of charge within the health system make provision for common mental disorders.

While the transfer of the approach undertaken in Sverdlovsk to other countries would require careful adaptation, taking account of differences in local context, culture and infrastructure, we believe the methods used here may have merit for policy makers and practitioners in other settings who are also looking at how best to foster the integration of mental health within primary care services.