In most of the world, mental health care consists of episodic treatments delivered by psychiatrists in specialized, often locked, facilities. This prevailing model is problematic for four reasons. First, it is too expensive. Teams of mid-level providers and community health workers can be deployed in less time and for a fraction of the cost of training and supporting a single psychiatrist. Second, it fails to achieve sufficient coverage. Even if we assume areas near specialized facilities have access to optimal mental health care (a debatable point), such concentration of resources leaves many areas too far away to maintain longitudinal care. This exacerbates the third problem, which is the overemphasis on treatment at the expense of prevention. The root causes of mental ill health are social as well as biological. If we focus only on the terrible cases that present to the psychiatric hospital, we will miss the forest for the trees. Finally, such treatment models promote stigma and fear surrounding the treatment of mental disorders. This is a particularly sensitive issue in countries where there has been a history of colonialism or violations of human rights by government authorities.
CASE ILLUSTRATION 2
Decades of civil war and authoritarian rule had ruined Liberia’s economy and destroyed its health system. Liberia’s people had suffered enormously. In some areas of the country, an estimated 90% of women had been raped, half of the population had fled the country or been internally displaced, and less than 20% of the population had a paying job. In 2008, a nationwide survey documented a massive burden of mental disorders. Forty percent of Liberian adults had major depression, 44% suffered from post-traumatic stress disorder, and 10% were actively suicidal. In contrast to the overwhelming need, Liberia had only a single psychiatrist, one psychiatric nurse, and one psychiatric facility located in its capital city.
The Liberian government recognized the importance of mental health for the overall health, development, and security of the nation. Several policy steps were taken. Mental health was included as one of six priority areas in the 2007 National Health Policy. Following this, Liberia formulated a National Mental Health Policy and a Basic Package of Mental Health Services (both notable achievements for a poor, post-conflict country). However, the actual implementation of these policies was constrained by weak physical infrastructure, overwhelmed health services, the absence of trained health workers, and limited financial resources.
In 2011, a disputed presidential election in neighboring Ivory Coast led to genocide-level violence. Over 180,000 Ivorian refugees fled into Liberia, carrying with them the trauma of recent violence and displacement from their homes. The Ivorian refugee crisis triggered a modest influx of international personnel and resources, creating a window of opportunity to strengthen Liberia’s fledgling mental health services.
How should mental health services be delivered? This remains an area of significant controversy and, at present, insufficient research. Nevertheless, five elements of best practice emerge from the current literature:
Packages of care.
Integration into primary care.
Direct action on the social determinants of health.
The following sections briefly describe each of these best practice elements. For students interested in reading further, we suggest several key references at the end of the chapter.
Collaborative care is team-based care facilitated by smart systems. Complex care pathways are boiled down to discrete tasks that may be shared across different members of the team. These team members may include community health workers, health coaches, social workers, psychologists, nurse care managers, nurse practitioners, physician assistants, primary care physicians, and/or psychiatrists. In the most enlightened models, patients, families, and communities are viewed as active team members with specific and outcome-relevant expertise and knowledge.
Protocols provide decision support (i.e., what to do when, when to ask for help, and when to refer), thereby enabling each team member safely and efficiently to perform tasks that might otherwise be outside their usual scope of practice. Smart tools further support this work. These tools range from paper-based population registries (e.g., lists of patients and active issues that facilitate coordination of care) to smartphone-based decision support and data entry applications.
A strong body of evidence indicates that collaborative care models are as or more effective than other ways of delivering mental health care. In addition to demonstrable efficacy, team-based care has the advantages of lower cost, increased coverage, and better resilience in cases of staff turnover.
The term “packages of care” refers to evidence-based bundles of interventions for specific MNS disorders. In settings where the need is great and resources are limited (the case for MNS disorders in most of the world), difficult decisions need to be taken regarding what treatments should be provided. A series of papers published in PLoS Medicine reviewed the evidence and proposed such packages of care. Table 8-1 is excerpted from one of these papers. It summarizes two evidence-based packages of care for depression, appropriate for low- and high-resourced settings.
Table 8-1.Packages of care for depression. ||Download (.pdf) Table 8-1. Packages of care for depression.
|Low Resourced Settings ||High Resourced Settings |
|Routine screening for detection ||High-risk or routine screening with confirmation of diagnosis by skilled clinician |
|Psychoeducation ||Psychoeducation |
|Generic antidepressants ||Choice of antidepressants |
|Problem-solving ||Choice of brief psychological treatments |
| ||Electroconvulsive therapy |
3. Integration into Primary Care
There are three compelling reasons for integrating mental health services into primary care. First, such integration locates services closer to people’s homes, thereby improving access and reducing costs associated with seeking specialist care in distant locations. Second, it minimizes stigma and discrimination while reducing the risk of human rights violations that may occur in psychiatric hospitals. And third, it generates good health outcomes at reasonable costs. Notably, such integration is not without its pitfalls. Collaborative planning, effective task-sharing among multidisciplinary team members, and adaptation to local context are important adjuncts to care integration. In its 2008 report, Integrating Mental Health Care into Primary Care: A Global Perspective, the WHO reviewed the evidence for integration of mental health services into primary care and presented ten best practice case studies from countries around the world. The Case Illustration 3 and Table 8-2 (summary of key messages) are excerpted from the WHO report.
Table 8-2.Key messages from who report, integrating mental health into primary care: a global perspective. ||Download (.pdf) Table 8-2. Key messages from who report, integrating mental health into primary care: a global perspective.
|Key messages of this report |
Mental disorders affect hundreds of millions of people and, if left untreated, create an enormous toll of suffering, disability and economic loss.
Despite the potential to successfully treat mental disorders, only a small minority of those in need receive even the most basic treatment.
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.
There is no single best practice model that can be followed by all countries. Rather, successes have been achieved through sensible local application of broad principles.
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.
To be fully effective and efficient, primary care for mental health must be coordinated with a network of services at different levels of care and complemented by broader health system development.
Numerous low- and middle-income countries have successfully made the transition to integrated primary care for mental health.
Mental health is central to the values and principles of the Alma Ata Declaration; holistic care will never be achieved until mental health is integrated into primary care.
CASE ILLUSTRATION 3
Juan from Chile has suffered from schizophrenia his entire adult life. Before integrated services for mental health in primary care were introduced, his condition was poorly managed and he was shuffled repeatedly in and out of a psychiatric hospital, where he endured and witnessed numerous human rights abuses. This part of his story is unfortunately all too familiar. However with the advent of primary care services for mental health in his community, Juan’s condition became well-managed and he was able to be reintegrated with his family. He hasn’t been back to the psychiatric hospital for four years now.
Excerpted from: WHO (2008) Integrating mental health into primary care: a global perspective. Geneva: World Health Organization and World Organization of Family Doctors (Wonca).
Quality improvement is the disciplined use of performance data to improve processes, systems, and outcomes. Various approaches exist. All share a focus on clearly defined goals, methods to link actions to outcomes, and steps to translate new lessons into better processes and systems. As distinct from research, which emphasizes methodological rigor at the expense of real world relevance, quality improvement takes a more pragmatic approach. Like the instrumentation of a plane, it provides continuous feedback on airspeed and altitude, enabling safe landings under difficult conditions. In multiple areas of health care, quality improvement has saved many lives at reasonable cost.
The application of quality improvement to mental health care, however, is in its infancy. The Institute for Healthcare Improvement’s Breakthrough Series for Depression demonstrated early success in the implementation and maintenance of quality improvement for depression treatment in the US primary care settings. Partners In Health and the Millennium Villages Project have begun to embed performance feedback systems into their community-based mental health programs in Haiti and Nigeria. Though the principles are sound, the evidence connecting quality improvement practices to measureable health outcomes is still forthcoming.
This should not deter the disciplined use of performance data to drive better outcomes in mental health care. Rather, we would suggest all health professional students (and indeed, all health professionals) learn the fundamentals of quality improvement and seek to apply the core principles in their daily practice. One note of caution: quality improvement processes, like all tools, are only as useful as the context and skill with which they are applied. Of particular relevance to global health and behavioral medicine, health students and professionals should marry the discipline of performance improvement to a nuanced understanding of local context (see The Importance of Context section).
5. Direct Action on the Social Determinants of Health
Mental, neurological, and substance use disorders and social determinants (i.e., the conditions in which people are born, grow, live, work, and age) are closely linked. On the one hand, the incidence of MNS disorders goes up with every step down in the social gradient. The poorest populations in every society have the highest rates of depression and alcoholism, for example. On the other hand, MNS disorders and social determinants actually drive one another in a vicious cycle, as summarized in Figure 8-2.
Vicious cycle of social determinants and mental disorders.
Source: Patel V, Lund C, Heatherill S, et al. Mental disorders: equity and social determinants. In Blas E, Sivasankara Kurup A., eds. Equity, Social Determinants, and Public Health Programmes
. Geneva: World Health Organization, 2010.
Given the complex range of social determinants that drive MNS disorders, traditional models of facility-based care seem ill prepared to address the root causes of disease (e.g., poverty, stigma, and local context). Rather, an approach that integrates clinical medicine with public health, community empowerment, and direct action on poverty and stigma is needed. Such an approach tends to reorient the usual workforce pyramid. Instead of the most highly trained providers at the top, it is the team members who are closest to the community that are best able to earn trust, understand the local context, and coordinate care in a patient- and community-centered way.