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Primary Care Mental Health

Integration And The

Evidence: Global Initiatives

Dr Gabriel Ivbijaro

MBBS FRCGP FWACPsych MMedSci DFFP MA

Chair Wonca Working Party on Mental Health & Editor in Chief

Mental Health in Family Medicine

There is no

health without

Mental Health

Primary care for mental health must be supported by other levels of care including :

community-based and hospital services

informal services

and self-care

Meet the full spectrum of needs

A European initiative

World Health Assembly Report 2009

Conventional health care vs primary people

centred care

Current trends (WHO 2008)

Too much emphasis on

centralization can lead to:

– Increased fragmentation

– Reduced access

– Increased costs

– Difficulty attaining holistic

care

This emphasizes the need

for primary care reforms

Evidence based summary –

health & primary care

• Countries with strong primary care have:

• Lower overall costs

• Generally healthier populations

• Within countries, areas with:

• Higher primary care physician (but NOT specialist)

availability have healthier populations

• Higher primary care physician availability have reduced

adverse effects resulting from social inequality

An integrated primary care system

Leadership is important at

all levels

Collaboration with policy

makers

Universality

Appropriate skills and

treatment available

mental health Gap Action Programme Scaling up care

for mental, neurological and substance use disorders

mhGAP

Today, with the launch of the Mental Health Gap Action Programme, we have reached a critical juncture. The long-standing failure to take action and make progress against these disorders is no longer acceptable. There are no excuses anymore.

Dr Margaret ChanDirector-General

World Health Organization

Launch of mhGAPGeneva, 9 October 2008



mhGAP

1 Unipolar depressive disorders 10.9%

2 Hearing loss, adult onset 4.6%

3 Refractory errors 4.6%

4 Alcohol use disorders 3.7%

5 Cataracts 3.0%

6 Schizophrenia 2.7%

7 Osteoarthritis 2.6%

8 Bipolar affective disorder 2.4%

9 Iron-deficiency anaemia 2.2%

10 Birth asphyxia and birth trauma 2.2%

Leading causes of years of life lived with disability

(Both sexes, all ages)

(WHO World Mental Health Consortium, JAMA, June 2nd 2004)

Gap in treatment:Serious cases receiving no treatment during the last 12 months

0

10

20

30

40

50

60

70

80

90

Developed countries Developing countries

Lower range Upper range Lower range Upper range

35%

50%

76%

85%

mhGAP 2009

High burden:

– 14% of the 2004 Global Burden of Disease measured in

Disability-Adjusted Life Years (DALYs) attributable to

mental, neurological and substance use disorders

Large treatment gap:

– 76-85% in developing countries for serious mental

disorders

mhGAP 2009

Defining the challenge:A high burden and large treatment gap

Mobilizing a global response:Five barriers to implementation

Political will to address mental health is low:

Incorrect belief that mental health care is cost-ineffective

Inconsistent and unclear advocacy between different groups of mental health advocates (professionals, users, families) and within each group

People with disorders are not organized in a powerful lobby in many countries

mhGAP 2009

Mobilizing a global response:Five barriers to implementation

Political will to address mental health is low

Mental health resources are centralized in urban areas and in large institutions

Difficulties in integrating mental health care in primary health care services

Mental health leadership often lacks public health skills and experience:

Those who rise to leadership positions are often only trained in clinical management

Public health training does not include mental health

mhGAP 2009

Gap in human resources:Number of psychiatrists per 100,000 population

Providing technical support:Catalysing change at country level

A joint collaboration

Acknowledgements

Acknowledgements

Wonca Other international contributors

Integrating mental health into primary care :

a global perspective

Part 1

Context and Rationale

Part 2

Best practices

Guidance and recommendations

Annex 1

Clinical implications for primary care workers

➡ Primary care

for mental health

within a pyramid

of health care

Rationale for

integration

: Primary care for mental health in context1Part

Primary care for mental health

Primary care for mental health forms an essential part of both:

• comprehensive mental health care

• general primary care.

General health care

Primary care

Mental health care


7 good reasons

for integrating mental health

into primary care

1. The burden of mental disorders is great

2. Mental and physical health problems are interwoven

3. The treatment gap for mental disorders is enormous

4. Primary care for mental disorders enhances access

5. Primary care for mental disorders promotes respect of human rights

6. Primary care for mental disorders is affordable and cost-effective

7. Primary care for mental disorders generates good health outcomes

7 good reasons

to integrate mental health into primary care

R² = 0.372

0

5

10

15

20

25

30

35

40

45

0 200 400 600 800 1000 1200

Su

icid

e &

self

in

flic

ted

in

jury

per

100000

Hospital beds per 100000

Europe : Hospital beds & suicide rates 2007Note : Only includes countries with data (tab Countries 2007 Sui and other)

R² = 0.128

0

5

10

15

20

25

30

35

40

45

0 20 40 60 80 100 120 140 160 180 200 220

Su

icid

e &

self

in

flic

ted

in

jury

per

100000

GPs per 100000

Europe : GP numbers & suicide rates 2007Note : Only includes countries with data (tab Countries 2007 Sui and other)

Evidence based summary –

health & primary care

• Countries with strong primary care have:

• Lower overall costs

• Generally healthier populations

• Within countries, areas with:

• Higher primary care physician (but NOT specialist)

availability have healthier populations

• Higher primary care physician availability have reduced

adverse effects resulting from social inequality

Mental disorders are prevalent

in primary care settings

Prevalence up to 60%

Principal mental disorders presenting in primary care settings:

– Depression (5% to 20%),

– Generalized anxiety disorder (4% to 15%),

– Harmful alcohol use and dependence (5% to 15%), and

– Somatization disorders (0.5% to 11%).

Special groups/issues

– Children (20 to 43%)

– Elderly people (up to 33%)

– Postnatal depression

– Post traumatic stress

Accessibility

Physical and financial access– Primary care centre is the closest health structure

Acceptability– Reduced stigma and discrimination of integrated services

– Cultural and linguistic consistence, familiar settings and staff, knowledge of community and social context

– Continuity of care

As a consequence,– Opportunities for mental health promotion, family and health

education

– Early identification and treatment of first episodes and relapses

Good health outcomes

Compelling evidence available from a range of settings

Primary care workers can

– Recognize a range of mental disorders

– Treat common mental disorders

– Deliver briefs interventions for the management of hazardous alcohol use

Guidance available

– e.g. NICE guidelines

12 best practices

on 5 continents

Analysis of 12 best practice examples

. Argentina

. Belize

. Brazil

. Chile

. United

Kingdom

. South Africa (2)

. Uganda

. Australia

. India

. Iran

. Saudi Arabia

10 principles for integrating

mental health into primary care1. Policy and plans need to incorporate primary care for mental health.

2. Advocacy is required to shift attitudes and behaviour.

3. Adequate training of primary care workers is required.

4. Primary care tasks must be limited and doable.

5. Specialist mental health professionals and facilities must be available to support primary care.

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

7. Integration is a process, not an event.

8. A mental health service coordinator is crucial.

9. Collaboration with other government non-health sectors, nongovernmental organizations, village and community health workers, and volunteers is required.

10. Financial and human resources are needed.

Report Conclusions

Integration ensures that the population as a whole has access to the mental health care that it needs

Integration increases the likelihood of positive outcomes for both mental and physical health problems

Health planners embarking upon mental health integration should consider carefully the 10 broad principles outlined in the report

Successful integration will also require reform in the broader health system.

Integration in NHS Waltham

Forest, London, UK

GP’s were asked to develop a Practice & Professional

Development Plan (PPDP)

– Practice visits to support this from 2001-3

– Included all practices in Waltham Forest

– Used proforma to collect data about practice in all

clinical areas provided by family doctors

– Used the information to understand individual practice

priorities and assess the standards of care patients

were receiving

42

Clinical audits completed by GP Practices

in 2001/2?

43

3432

21

96

42 2 2 2 2

0

5

10

15

20

25

30

35

40

Dia

bet

es

CH

D /

IHD

/ H

yper

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tati

ns

Ast

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olo

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Gen

eric

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g

Flu

Vac

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Dea

ths

Th

yro

xin

e

An

ti-h

ist

GI d

isea

se

Ch

ild S

urv

eilla

nce

Audits Undertaken at GP practices (2001/2)

No of practices

% of practices

Practice targets as priorities for clinical

improvement?

44

Areas of focus for Clinical Governance (2001/2)

70

62

28

21 21 2119

1511 11

96

0

10

20

30

40

50

60

70

80

CH

D / ID

H /

Hyp

ert

en

sio

n

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be

tes

Ce

rvic

al

Cyt

olo

gy

Ast

hm

a c

are

Ge

ne

ric

pre

scrib

ing

Ris

k

Ma

na

ge

me

nt

Inte

gra

ted

ca

re

pa

ths

po

st M

I

Imm

un

isa

tion

s

Te

en

ag

e

pre

gn

an

cy

Te

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He

alth

Pro

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Me

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No practices

% of practices

What did the PPDP visits tell us?

Mental health was of low priority for most GP

practices

Management of long term physical conditions

and IT were high priority

Areas of high priority tended to have financial

implications for GP practices

45

Mental Health In Waltham Forest 2008:

A SummaryIndicator %

Achieve

d

Dep 1 - CHD/ diabetics with depression case finding

(total CHD/diabetes register size 16 110)

87

Dep 2- Patients with depression who have completed severity rating

tool

(total depression register size 11 783)

89

MH 4 - % of patients on lithium with creatinine /TSH

(total SMI register size 2639)

96

MH 5 - % with lithium in therapeutic range 87

MH 6 - % of BPD/schizophrenia with care plan

MH 7 - % of annual review DNA’s followed up in 14 days 80

MH 8 - % of practices with SMI disease register (Schizophrenia,

BPD, other psychoses)

93

MH 9 - % with annual health review 90

What does this example illustrate?

• There has been an increased interest in prioritising

mental health since introducing QOF

• Standards achieved against outcome measures are

above 80%

• Empowering GP’s to deliver mental health does

work but requires collaboration between the

government, the Colleges, medical unions and

patient groups to make it happen

Providing technical support:Catalysing change at country level

Identify the intervention package adapted to the local context

Integrated into the existing primary health services

Developing implementation strategies for community, primary and referral facility levels

Strengthening the health system supports required to deliver the interventions e.g. drugs, equipments

Improving links between communities and health systems



mhGAP

Wonca Collaboration


Primary care for mental health forms an essential part of both:

• comprehensive mental health care

• general primary care.

General health care

Primary care

Mental health care


Thank [email protected]

Health & Medicine

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