Dr. JIBRIIL HANDULEH, MBBSGUEST SPEAKER

AMOUD UNIVERSITY WORKSHOP: BASIC MENTAL HEALTH

I.NEZ-LMU,JIMA UNIVERSITY AND UNIVERSITY OF HARGEISAHARGEISA,SOMALILAND JANUARY, 23.-25. 2012

Integrating Mental Health services into Primary Care

Integrating Mental Health Services into

Primary Care

Introduction In many years mental health services were

separate from general practice.Mental disorders have been largely overlooked

as part of strengthening primary care. This is despite the fact that mental disorders

are found in all countries, in women and men, at all stages of life, among the rich and poor, and in both rural and urban settings.

It is also despite the fact that integrating mental health into primary care facilitates person-centered and holistic services, and as such, is central to the values and principles of the Alma Ata Declaration.

Background informationCommon mental health disorders had been

neglected at PHC level.Mental disorders affect hundreds of millions of

people and, if left untreated, create an enormous toll of suffering, disability and economic loss.

Integrating mental health services into primary care is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need.

Primary care for mental health is affordable, and investments can bring important benefits.

Certain skills and competencies are required to effectively assess, diagnose, treat, support and refer people with mental disorders; it is essential that

primary care workers are adequately prepared and supported in their mental health work.

Integration is most successful when mental health is incorporated into health policy and legislative frameworks and supported by senior leadership, adequate resources, and ongoing governance.

Numerous low- and middle-income countries have successfully made the transition to integrated primary care for mental health.

Good reasons to integrate mental health into PHCthe burden of mental disorders is greatMental and physical health problems are

interwoven the treatment gap for mental disorders is

enormousPrimary care for mental health enhances

access

Primary care for mental health promotes respect of human rights.

Primary care for mental health is affordable and cost effective

Primary care for mental health generates good health outcomes

Source: The 2008, Mental health integration into primary health care , WHO , WONCA report.

Principles of integrating mental health into primary health care Policy and plans need to incorporate primary

care for mental health.Advocacy is needed to shift attitudes and

behaviors. Adequate training of primary care physicians.Tasks must be limitedSpecialist mental health service must be

available to support primary care physicians when needed.

Patients must have access to essential psychotropic medications in primary care.

Integration is a process, not an eventMental health service coordinator

needed( country level)collaboration with other government non-

health sectors, nongovernmental organizations, village and community health workers, and volunteers is required.

Financial and human resources are needed particularly for service sustainability.

Current and projected ranking of contributors to the global burden of disease Disease or injury 2002 Rank 2030 Rank Change in

rank  Perinatal conditions 5 4 -4

LRTI 2 8 -4 HIV/AIDS 3 1 +2 Depressive disorders 4 2 +2 Diarrhoeal diseases 5 12 -7 Ischaemic heart disease 6 3 +3 Cerebrovascular disease 7 6 +3 Road traffic accidents 8 4 +4

Mental health in GP practiceMental illness is covert or hiddenPrimary carers fail to recognize one out of

two patients with mental illnessesIncidence of mental illness varies in

different areas and practices and at different times

Untreated mental illness is time-consuming and costly

The cost of untreated mental illness:WHO “Burden of Disease” studyTo patient

Morbidity, mortality, financial, productivity, family suffering, reputation

To communityProductivity, financial, loss of

community cohesionTo doctor

?

Obstacles to mental health diagnosisPatient

Ignorance, stigma, fear of the implications, lack of finances or resources to treat

DoctorKnowledge and/or skill deficit, attitude,

misinterpretation or interest issues, lack of facilities and resources, time, remuneration issues, discomfort with emotional issues (personal or cultural)

SocietyDifferent priorities, financial, lack of

community education, health policy, community attitudes

What are the challenges in Somaliland/Somalia practice???

Association Between Physical & Mental Problems in Primary Care Patients

10-20% of general population will seek primary care for a MH problem

Studies show prevalence of mental health problems:PRIME-MD: average 26% have psychiatric disorder

while another 13% have significant functional impairment

WHO: average of 21% had psychiatric disorders

2/3 of primary care patients with psychiatric diagnosis have significant physical illness

The GP perspective

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General practice is total (bio-psycho-social) and should address continuing patient care in the context of their family and community

The GP has an ongoing relationship with the patient and their family

General practice provides opportunity for early diagnosis before the condition is well-defined or fully developed

The GP sees the patient before they are “educated” by the process of investigation and elimination

The main mental illnesses seen in General Practice

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Depression and anxiety are the major mental illnesses, alone or co-morbid, or as manifestations of other mental conditions or medical illness

Both depression and anxiety have a range of severity and forms

Specificity of diagnosis is importantSomatisation is very common: the mind and body

are one also patient prefers to c/o an illnessDrug use and illness must be excludedAny illness the GP needs to consider the full

circumstances of the patient

Association Between Physical & Mental Problems in Primary Care Patients

Chronic medical illness increases probability of depression by two to three folds

Psychiatric disorders in primary care are less severe than those in MH settings

Health status, quality of life, functional status-better correlated with psychosocial factors than physical disease severity

Medical Outcome Study (MOS) indicates functional impairment due to depression compares to that of COPD, diabetes, CAD, hypertension, and arthritis

Recognition & Treatment of MH Problems in Primary Care

1/2-2/3 of patients meeting criteria for psychiatric diagnosis go unrecognized by primary care providers

Even when recognized & treated, dosage & duration of antidepressant meds are usually inadequate

In naturalistic studies, there was no difference in outcome between treated and untreated depressed patients in primary care setting.

Health Care Utilization Studies indicate objective disability or morbidity alone can

predict only 10-25% of health care use

One study found 60% of all medical visits were by “worried well” with no diagnosable disorder

Patients with MH problems, when compared to unaffected counterparts, use twice the medical resources.

Patients with somatization disorder use 9 times national norm of medical resources

Why Should Primary Care Providers Integrate MH Services Into Primary Care?

Primary Care Providers deal with patient’s untreated psychological problem- identified or not

Psychosocial/behavioral problems take up Primary Care Provider time regardless of degree to which problems are explicit focus of practice

1/3-1/2 of Primary Care patients will refuse referral to MH professional

Why Should Primary Care Providers Integrate MH Services Into Primary Care?

Patients who refuse referral tend to be high utilizers with unexplained physical symptoms

Dichotomizing patients problems into physical & mental leads to:Duplication of effortUndermines comprehensiveness of careHamstrings clinicians with incomplete dataInsures that the patient cannot be completely

understood

Why Should Primary Care Providers Integrate Mental Health Services Into Primary Care?

Many prefer to receive MH services in Primary Care because not construed as “mental healthcare”

With expectation of seriously mentally ill, basic MH services can be managed in Primary Care setting

Growing evidence that integrated primary care is cost-effective

Benefits of MH in the PHCWill reduce stigma and discriminationWill reduce costs to seek specialist in

a distant location.Remove the risk of human rights

violation Good health outcomes.Source: The 2008, Mental health integration

into primary health care , WHO , WONCA experiences in dozens of countries.

Barriers to Providing Mental Health Services to Primary Care Patients

Competing Demands and Tasks of Primary Care Providers

Average primary care visit last 13 minutesPatients have average of 6 problems on problem listInadequate time to adequately assess for mental health

problems and manage once assessedA zero-sum game. No room for provision of new

services without eliminating another or adding resources for additional work

Barriers to Providing Mental Health Services to Primary Care Patients

Limitations of Specialty Mental Health Service for Primary Care SettingFocus of Psychiatry is increasingly on diagnosis of

seriously disturbed patients and prescription/monitoring of psychotropic medication

Psychiatric diagnostic systems that do not fit clinical phenomenology

Mental Health Providers not trained to address psychological/behavioral problems common in primary care settings somatizationchronic painnoncompliance with medical regimens

Barriers to Providing Mental Health Services to Primary Care Patients

Patient Barriers to Providing Mental Health ServicesConcerns about stigma of psychiatric diagnosisSignificant negative consequences for pursing mental

health careDomestic abuseCriticism from family

Patient Somatization: Problems not perceived as psychological

Patient has no psychiatric diagnosis, but still in need of psychological care

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level One: Minimal Collaboration - Providers in Separate Locations

Separate systemsRarely communicate about patientsMost private practices and agenciesHandles adequately problems with little biopsychosocial

interplay & few management difficultiesHandles inadequately problems that are refractory to

treatment or have significant biopsychosocial interplay

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level Two: Basic Collaboration on Site

Separate systems but share same facilityNo systematic approach to collaboration - do not share

common language or in-depth understanding of each other’s worlds. Misunderstandings are common

Common in mental health settingsHandles adequately problems with moderate bio-psycho-

social interplay requiring occasional communication about shared patients

Handles inadequately patients with ongoing and challenging management problems

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level Three: Close Collaboration in Fully Integrated System Same site, same vision, and same system in a

seamless web of biopsychosocial services Staff committed to biopsychosocial systems paradigm. In-depth understand of each other’s roles/cultures. Operates as a team - regular collaboration

Models of Collaboration Between Primary Care and Mental Health Care Providers

Continued... Level Three: Close Collaboration in Fully Integrated

SystemFairly rare. Occurs in some hospice centers and special

training and clinical settings.Handles adequately most difficult and complex

biopsychosocial problems with challenging management problems

Handles inadequately problems when resources of health care team are insufficient or when there is breakdown with larger service system

Global effortsIn 2008, WHO developed the MHGAP

curriculum guide for the low and middle income countries.

Several countries have now adopted it for primary care physicians.

Amoud medical school will give the guide as part of mental health undergraduate teaching in January 2012.

MH Gap Guide addresses Depression PsychosisSchizophreniaManiaAlcohol and substance misuseSuicide Assessment sheetsCognitive disorders

Mental health and physiciansPrimary care physicians don’t have mental

health education after leaving medical school.

Primary care physicians meet with psychiatric patients suffering from co-morbid medical conditions.

Some try meds usually without psychiatric assessment

MH in the PHC settings SomalilandMental health care in Primary care setting

Integrating mental health into Primary health care In Somaliland Where Clients go to get PHC?

What they receive in PHC? how do you think Physicians and

nurses would identify mentally ill client who may have interwoven presentation?

Do Primary care providers think on mental health disorders during patient assessment?

Clients in the PHC including MH patientsPharmacistsPrivate ClinicsMCH settings

Source : UNICEF Somalia , September 2011

Why integration of MH into Primary health care in SomalilandThere is huge gap in mental health treatmentMost of clients have no access to mental health

hospitalThey are relatively poorThey come into primary health care for

physical sounding diseases which are neuropsychiatry presentations

They get some misdiagnosis

Do you know the most common misdiagnosis made here?

THYPHOID FEVER Many mental ill clients had been said to

have it.

How to correct this?

Example of mental health integration into PHC in Somaliland- Borama story

Mental health OPD setting within the teaching hospital

Integration of mental health in PHC-The first model in Somaliland-Borama styleMental health service in the community settingHome visit

Teaching school teachers on mental health in the classrooms

Conclusions

Mental healthcare cannot be divorced from primary medical care - all attempts to do so are doomed to failure

Primary care cannot be practiced without addressing mental health concerns, and all attempts to neglect them will result in inferior care

deGruy, F.V. (1997). Mental healthcare in the primary care setting:

A paradigm problem. Fam. Syst. & Health 15:3-26.

Any questions Thank you very much for listening