On the Occasion of the World Mental Health Day Minding the Gap in Mental Health: The Health Promotion-Primary Care-based Solution

Originally, public health actions turned to the living conditions that prevented the development of countries in the process of increasing urbanization, especially protecting their workers and tackling economic losses. The actions were primarily directed to infectious diseases. Today, the process of urbanization in most countries of the world is consolidated, and new health problems that affect communities’ quality of life should be addressed, with special attention to non-communicable-diseases (NCDs) (Beaglehole et al., 2011).[1] Among NCDs, mental disorders are highly prevalent and the gap between this fact and the low proportion of individuals that receive proper care, mainly in low- and middle income countries, has been pointed by World Health Organization (WHO) (WHO, 2010).[2] In this October, 10^th day is being commemorated the 20^th anniversary of World Mental Health Day[3] and it is timely discuss effective and practical solutions to take care of that gap.

Mental health is defined by WHO as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. It can refer to a comprehensive range of health activities and actions including “the promotion of well-being, the prevention of mental disorders, and the treatment and rehabilitation of people affected by mental disorders”[4]. Then, any proposal to mind that mental health gap probably would not be a simple or single solution but comprehensive and complex. Among the potential solutions two, if strategically integrated, could have an important impact on the improvement of mental health around the world: Health Promotion and Primary Care.

In this more modern conception, “Health Promotion” is the process of strengthening and empowering individuals and communities (municipalities, associations, schools, institutions of commerce and industry, labor organizations, media) in order they may expand their ability to control the determinants of health and improve their quality of life (Breslow, 1999).[5] It considers and highlights the society's intersectoral actions and implementation of a community environment of well-being. Thus, the “new” health promotion is to give people and communities the means to improve their overall - including mental - health and exercise more control over it. Concrete examples of it are public policies that promote-out of the health sector - healthy eating, physical activity, contemplative practices, tobacco control, reduction of alcohol and other drugs use, reduction of morbidity and mortality due to traffic accidents, violence prevention and encouraging the culture of peace and a supportive social net into communities.

Also related to “Health Promotion”, any public policy that aims to promote mental health should be designed to strongly involve workplace as a key space for actions. The majority of developed and developing countries population now lives in cities and is formally or informally linked to workplaces where most of its productive life is spent (ILO, 2011).[6] Studies have shown the importance of the work environment, both in the generation and prevention of mental disorders (D’Souza et al, 2003),[7] but still a few countries have made policies that effectively regulate or make partnerships with companies and corporations regarding workplaces environment and health promotion. Interestingly, even among mental health workers, work-related mental disorders are highly prevalent (Paris and Hoge, 2010).[8] Thus, rethinking work environments and process as key areas for public health actions should also be part of a global agenda to tackling the current critical scenario, and the incorporation of successful experiences and effective promotion of physical activity, decreased levels of stress, environment and ergonomic improvements, control of tobacco should no longer be local initiatives but a public health policy worldwide.

It is well known that the defining attributes of “Primary Care” (PC), especially first contact access, long-term person-(not disease) focused comprehensive care and coordination correspond to the health needs of people with mental disorders. Integrating mental health into PC services can bring care to where individuals are, with concomitant improvement in clinical outcomes, for example, lowering the rate of utilization of services at all levels of care, including hospital admissions. Other data also justify this integration: people with mental health problems are often untreated or irregularly followed-up, and are more likely to be seen annually by PC services than for specialized mental health medical services, therefore, PC services may be in a better position to recognize and improve rates of treatment of these patients; many individuals with mental disorders have multimorbidity, and mental health problems may worsen disability associated with these co-disorders (such as cardiovascular disease or pulmonary, diabetes or arthritis), and then integrated treatments can potentially reduce overall health costs and improve quality of life of these patients; there is also consistent evidence that common mental disorders can be effectively cared in the context of PC (Butler et al., 2008).[9]

In conclusion, to strengthen and integrate Health Promotion and Primary Care into communities around the world are key strategies to mind the mental health gap and should be central in any public health agenda for tackling it. If, we succeed or not in this way probably will define that we will or not commemorate the 40^th anniversary of World Mental Health Day without that gap.