Making primary care count in mental health provision

In countries with few resources, some recovering from conflict, mental healthcare does not generally receive the attention it deserves. But there is also inequity of provision in well-funded systems. In both contexts, clinically beneficial and cost-effective care can be built from the bottom up. A WPA session on primary care heard contrasting but complementary accounts of how this can be done.

Provision of mental healthcare is often represented as a pyramid, with self-care and informal community care at its base, service provision by workers in primary care in the middle, and -- at the apex -- specialized psychiatry, which is reserved for the most severely ill.

Implementing this structure is especially important in countries with low and middle income, where psychiatrists are few. In the whole of southern Sudan, for example, there is only one psychiatrist, Claire Whitney (Jordan-based International Medical Corps Global Mental Health and Psychosocial Support Advisor) told at the meeting.

In situations of high humanitarian need, where communities have been disrupted by conflict or disaster, the situation is even more critical. An effective strategy is to build the capacity of non-specialists.

Integrated mental health services are more available, accessible and non-stigmatizing

Psychosocial support in emergency settings

The International Medical Corps has helped in more than 70 countries, using a step-wise approach that starts with identifying needs and resources and gaining the co-operation of those already involved.  This is followed by training primary providers in pharmacological and non-pharmacological interventions. Then – where possible – there is the organization of pathways of referral to more specialized services. This may require networking and advocacy at government level. The final step is to ensure the sustainability of the services that have been organized.

An online toolkit describes the integration of mental health into general health provision in emergency settings.1

Introducing the plenary session, Saul Levin, CEO of the American Psychiatric Association, emphasized the importance of collaboration between primary care and specialized psychiatric services. It was a theme taken up by Amanda Howe, Professor of Primary Care at the University of East Anglia, UK.

Integration of services

Primary care provision for those with mental health problems can be affordable and can be effective, she argued. But there needs to be integration including established routes of referral to more specialized mental health services, access to them as a source of advice, and facilities for exchanging information.

A consultation that reveals a mental health problem can be a rewarding “dance of discovery”

Family doctor involvement should be driven by values and beliefs, and not just by practical considerations. But the idea does have many practical advantages: the physician is likely to have known the patient for many years, is aware of their physical health problems and social circumstances, and can at least in theory access community support from outside the practice.

That said, the primary care team – and it is not only doctors, but the full range of health professionals – needs to be appropriately trained, and there needs to be provision for reimbursement. Quick fixes don’t work for complex situations, she said.

Quick fixes don’t work for complex situations

The World Organization of Family Doctors2 (WONCA) has a mental health working party that exists to promote primary care involvement.

Primary care should engage in the prevention of mental ill-health and the promotion of positive health, as well as the identification of problems and their management 

Ideally, primary care should engage in the prevention of mental ill-health and the promotion of positive health, as well as the identification of problems and their management.  A key to the latter is a consultation that is open to the emergence of mental health issues – a process that Professor Howe described as a rewarding “dance of discovery”.