Vimal Kumar Sharma*
Faculty of Health and Social Care, University of Chester, UK
Received Date: July 05, 2017; Accepted Date: July 14, 2017; Published Date: July 21, 2017
Citation: Sharma VK (2017) Mental Health and Primary Care. J Healthc Commun. 2:49. doi: 10.4172/2472-1654.100090
Mental ill-health is a leading cause of disability and most people with mental health problems approach their primary care doctors for help. One in four consultations in primary care is mainly due to mental health related issues. Yet mental health hasn’t received due attention so far in primary care setting.
The main challenges in taking mental health services at primary care level include limited mental health specialists, low priority given to mental health, Inadequate training and skills of primary care workforce, Inadequate specialists’ support to primary care workers as well as negative attitude and stigma towards metal illness. Investing in work force’s training and education in identifying and managing mental disorders at primary care is the only way forward to address the huge treatment gap exists for mental illness. The use of technology and computers may assist this process further. An example is use of a pragmatic computer assisted diagnostic and treatment tool such as GMHAT/PC. Psychiatrists and other mental health professionals need to change their mind-set to work differently by supporting primary care workers, spending more time in training front line workers and taking some leadership in keeping the mental health agenda high up in policy makers’ list.
Primary care; Cardiovascular; Mental disorders; Health system; Health professionals
Mental health problems are one of the leading causes of disability in the world  leading to significant direct and indirect costs to society [2,3]. In a large scale study , over one fourth of people in the USA over the age of 18 were found to have a diagnosable mental disorder. Mental illnesses are also the second most important cause of reducing quality adjusted life years after cardiovascular conditions. A house hold survey in the USA  looking at the relationship of physical and mental disorders with disability, found that the number of disability days associated with all mental conditions accounted for more than half the number of disability days associated with all physical conditions. The significant impact of mental illnesses can be attributed to their high prevalence as well as substantial co-morbidity with physical conditions. Despite the high disability associated with mental illnesses, they remain under-treated in both low to high income countries . World Health Organisation [7,8] in its Mental Health Gap Action Programme (mhGAP) highlighted that four out of five people with mental disorders in low-middle income countries fail to receive treatment for their mental conditions. The treatment gap for mental disorders remains 50-60% even in most developed countries.
International leaders and policy makers in health have been emphasising the role of primary care in addressing the health care needs of any given population for over four decades. Declaration of Alma-Ata  in 1978 was the major mile stone in at least raising awareness of need of health provision for all in every part of the world. The declaration highlighted that the health is a fundamental human right; the gross inequalities in health between developing and developed countries as well as with in countries need reducing; People have right and duty individually as well as collectively in the planning and delivery of their health care; Primary health care is the back bone of health care delivery system of any country and providing acceptable level of all the people of the world by the year 2000. More than a decade of the target year, mental health services remain far from satisfactory at primary care level in most countries.
Following the Alma Ata declaration of 1978 the WHO in its World Health Report of 2008  stressed the urgent need to strengthen primary health care world-wide. The existing health delivery systems fail to meet the populations’ health needs. People from all over the world deserve a health system that is person- centred, comprehensive, provides continuity, and is well integrated. A well planned primary care health can meet all these objectives.
Mental Health despite being a leading cause of disability worldwide is not well incorporated at the primary care level even in the most developed countries. Most people with mental illness seek help from their primary care doctors and many of them present with physical symptoms. Health professionals in general often fail to recognise mental illnesses, especially when they coexist with physical conditions. It is worth noting that people with physical illness have a raised psychiatric morbidity. A cross-national study  of the joint effect of mental and physical conditions on disability found that co-morbidity exerts detrimental synergistic effects. It therefore recommended that clinicians need to deal with both mental and physical conditions giving them equal priority if they are to manage co-morbidity and reduce disability.
It is important to understand the reasons for poor recognition and treatment of mental disorders in general so that positive steps can be taken at all levels to address the issue effectively. The main barriers occur at three levels. Firstly, patients may find it hard to acknowledge that their problems are mental health related especially if they are experiencing the problem for the first time . Equally, people find it hard to accept they have a mental illness even if they acknowledge that they suffer from mental health problems. The findings of the National Comorbidity Survey replication on people with common mental disorders in the US  concerning patients’ perceived barriers to mental health treatment, revealed that: (a) A low perceived need for treatment was the main reason for not seeking help especially among those who only had mild to moderate problems; (b) The majority of people with more severe disorders reported they wished to handle their problems on their own. About a quarter felt that the problem was not severe enough to seek help or would be likely to recover spontaneously; (c) Over one third of respondents who dropped out of treatment altogether reported an “attitudinal/evaluative barrier” such as stigma, negative therapeutic experience or low quality of treatment.
Secondly, barriers occur at service provider level, mainly due to primary care service providers’ attitudes towards mental illness, their knowledge, training and experience of dealing generally with mental disorders. Their own time pressures, a belief that making a proper diagnosis of mental illness was burdensome, inadequate knowledge about diagnostic criteria or treatment options, general lack of a psychosocial orientation, and inadequate insight into the different cultural presentations of mental disorders were other barriers of poor recognition of mental illness. It could be concluded that primary care health professionals’ inadequate training in mental illness, recognition and management coupled with a lack of available user-friendly clinical aids for the diagnosis and treatment of mental disorders in primary care settings is an important service barrier.
The third but important barrier occurs at an organisational level due to the State's mental health related policies and those created by local systems. The priorities directed at mental health care are sometimes half hearted, ranging from public health policy to the resources provided for care to "hard to reach" groups . Local System barriers include productivity pressures, limitations of third-party mental health coverage, restrictions on specialist, medication and psychotherapeutic care, lack of a systematic method for detecting and managing such patients, and lack of continuity of care.
Integrating mental health in general health at primary care level is the only solution to meet the mental health needs of population. World Health Organisation in the Mental Health Gap Action Programme (mhGAP) highlighted an immense treatment gap, that can only be reduced by training frontline health workers in mental health so that they can identify, diagnose and mange mental health problems in the primary care setting them as far as possible. The mhGAP has provided intervention guidelines  (mhGAP-IG) for non-mental health workers on identifying and managing priority conditions such as depression, psychosis, bipolar disorders, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, Sustenance misuse, self-harm and other emotional or medically unexplained complaints. Lund et al. [15,16] developed a programme to reduce treatment gap for mental disorders (PRIME) for low-middle income countries and a detailed evaluation process. The programme incorporate mhGAP-IG aimed at up-skilling health workers. The PRIME package targeted community level (frontline workers), Health Care facility level (health centre) and organisational level (district health administration). Initial PRIME field trials in five countries Ethiopia , India , Nepal , South Africa  and Uganda  have shown some promising findings. Three of the five trials (India, Nepal and Ethiopia) included mostly rural population. These studies identified various challenges of integrating mental health in primary care level. A sufficient length of mental health training, ongoing support from specialist, making medicines and other resources available at primary care level are some of them.
The author has long standing interest in integrating mental health services in primary care [22-24] (Sharma 2015) and in developing mental health assessment tools suitable for primary care the Global Mental Health Assessment Tool (GMHAT) (Sharma and Copeland). The primary care version- GMHAT/PC is a semi-structured, computer-assisted clinical assessment tool that is developed to assist health workers in making quick, convenient and comprehensive standardised mental health assessments in both primary and general health care. The assessment program starts with basic instructions giving details of how to use the tool and rate the symptoms. The first two screens help in getting brief background details including present, past, personal and social history including trauma, epilepsy and learning disorder. The following screens consist of a series of questions leading to a comprehensive yet quick mental state assessment. They start with two screening questions about every major symptom complex followed by additional questions only if the screening questions are answered positively. The questions cover the following symptom areas: worries, anxiety and panic attacks, concentration, depressed mood, including suicidal risk, sleep, appetite, eating disorders, hypochondriasis, obsessions and compulsions, phobia, mania, psychotic symptoms, disorientation, memory impairment, alcohol misuse, illegal drug misuse, personality problems and stressors. The questions proceed in a clinical order along a tree-branch structure. The GMHAT/PC has been widely tested and now being tried to detect and manage mental disorders in primary and general health settings in English [25,26], Hindi , Arabic  and Spanish . Further translations in various languages are in progress. The GMHAT team has also developed a two to three days mental health training program for frontline workers to provide knowledge and skills to identify, diagnose and manage mental disorders at primary care level. The findings of field trials are promising and detailed in a book recently published by Indian Psychiatry Society . GMHAT/PC may prove to be very useful clinical tool for frontline health workers in association with mhGAP-IG.
A two to five days training program on mental health based around GMHAT/PC has been developed by University of Chester in association with Cheshire and Wirral NHS Foundation Trust to equip primary care workers in detecting and managing wide range of mental disorders in primary care. Initial feedback from primary care workers of the value of such course is very positive. We have to wait to evaluate the sustained effect of such training. Such training programmes and tools coupled with on-going support from specialist mental health services to the primary care health staff is the only way forward to overcome the service needs of people with mental health problems in primary care.