Teaching session at Mansoor Hotel Hargeisa, Somalia for health car professionals on mental health in primary care

1. Dr. JIBRIIL HANDULEH, MBBS
GUEST SPEAKER
AMOUD UNIVERSITY
WORKSHOP: BASIC MENTAL HEALTH
I.NEZ-LMU,JIMA UNIVERSITY AND
UNIVERSITY OF HARGEISA
HARGEISA,SOMALILAND
JANUARY, 23.-25. 2012
Integrating Mental Health services
into Primary Care

2. Integrating Mental Health
Services into Primary Care

3. 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.

4. Background information
Common 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.

5. 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.

6. Good reasons to integrate mental
health into PHC
the burden of mental disorders is great
Mental and physical health problems are interwoven
 the treatment gap for mental disorders is enormous
Primary care for mental health enhances access

7. 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.

8. 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 limited
Specialist mental health service must be available to support
primary care physicians when needed.
Patients must have access to essential psychotropic
medications in primary care.

9. Integration is a process, not an event
Mental 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.

10. 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

11. Mental health in GP practice
Mental illness is covert or hidden
Primary carers fail to recognize one out of two patients with
mental illnesses
Incidence of mental illness varies in different areas and
practices and at different times
Untreated mental illness is time-consuming and costly

12. The cost of untreated mental
illness:
WHO “Burden of Disease” study
To patient
Morbidity, mortality, financial, productivity,
family suffering, reputation
To community
Productivity, financial, loss of community
cohesion
To doctor
?

13. Obstacles to mental health diagnosis
Patient
Ignorance, stigma, fear of the implications, lack of finances or
resources to treat
Doctor
Knowledge and/or skill deficit, attitude, misinterpretation or
interest issues, lack of facilities and resources, time,
remuneration issues, discomfort with emotional issues
(personal or cultural)

14. Society
Different priorities, financial, lack of community education,
health policy, community attitudes
What are the challenges in Somaliland/Somalia practice???

15. 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

16. The GP perspective
COPYRIGHT © IAN M CHUNG 2005
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

17. The main mental illnesses seen in General
Practice
COPYRIGHT © IAN M CHUNG 2005
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 important
Somatisation is very common: the mind and body are one also
patient prefers to c/o an illness
Drug use and illness must be excluded
Any illness the GP needs to consider the full circumstances of
the patient

18. 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

19. 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.

20. 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

21. 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

22. 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 effort
Undermines comprehensiveness of care
Hamstrings clinicians with incomplete data
Insures that the patient cannot be completely understood

23. 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

24. Benefits of MH in the PHC
Will reduce stigma and discrimination
Will 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.

25. Barriers to Providing Mental Health Services
to Primary Care Patients
 Competing Demands and Tasks of Primary Care Providers
Average primary care visit last 13 minutes
Patients have average of 6 problems on problem list
Inadequate time to adequately assess for mental health problems and manage
once assessed
A zero-sum game. No room for provision of new services without
eliminating another or adding resources for additional work

26. Barriers to Providing Mental Health Services
to Primary Care Patients
 Limitations of Specialty Mental Health Service for Primary Care Setting
Focus 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
 somatization
 chronic pain
 noncompliance with medical regimens

27. Barriers to Providing Mental Health Services
to Primary Care Patients
 Patient Barriers to Providing Mental Health Services
Concerns about stigma of psychiatric diagnosis
Significant negative consequences for pursing mental health care
 Domestic abuse
 Criticism from family
Patient Somatization: Problems not perceived as psychological
Patient has no psychiatric diagnosis, but still in need of psychological care

28. Models of Collaboration Between Primary
Care and Mental Health Care Providers
 Level One: Minimal Collaboration - Providers in Separate
Locations
Separate systems
Rarely communicate about patients
Most private practices and agencies
Handles adequately problems with little biopsychosocial interplay & few
management difficulties
Handles inadequately problems that are refractory to treatment or have
significant biopsychosocial interplay

29. Models of Collaboration Between Primary
Care and Mental Health Care Providers
 Level Two: Basic Collaboration on Site
Separate systems but share same facility
No 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 settings
Handles adequately problems with moderate bio-psycho- social interplay
requiring occasional communication about shared patients
Handles inadequately patients with ongoing and challenging management
problems

30. 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

31. Models of Collaboration Between Primary
Care and Mental Health Care Providers
Continued...
 Level Three: Close Collaboration in Fully Integrated System
Fairly 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

32. Global efforts
In 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.

33. MH Gap Guide addresses
Depression
Psychosis
Schizophrenia
Mania
Alcohol and substance misuse
Suicide
Assessment sheets
Cognitive disorders

34. Mental health and physicians
Primary 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

35. MH in the PHC settings
Somaliland
Mental health care in Primary care setting

36. 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?

37. Clients in the PHC including MH
patients
Pharmacists
Private Clinics
MCH settings
Source : UNICEF Somalia , September 2011

38. Why integration of MH into Primary
health care in Somaliland
There is huge gap in mental health treatment
Most of clients have no access to mental health hospital
They are relatively poor
They 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?

39.  THYPHOID FEVER
 Many mental ill clients had been said to have it.
 How to correct this?

40. Example of mental health integration
into PHC in Somaliland- Borama story
Mental health OPD
setting within the
teaching hospital

41. Integration of mental health in PHC-
The
first model in Somaliland-Borama styleMental health service
in the community
setting
Home visit
Teaching school
teachers on mental
health in the
classrooms

42. 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.

44. Any questions
Thank you very much for listening