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Wonca/WHO Primary Care Mental Health Factsheet

What is primary care mental health?

WHO and Wonca Working Party on Mental Health

What is primary healthcare?

Primary healthcare is about providing ‘essential

healthcare’ which is universally accessible to indi-

viduals and families in the community and provided

as close as possible to where people live and work. It

refers to care which is based on the needs of the

population. It is decentralised and requires the active

participation of the community and family.1

Providing mental health services in primary

healthcare involves diagnosing and treating people

with mental disorders; putting in place strategies to

prevent mental disorders and ensuring that primary

heathcare workers are able to apply key psychosocial

and behavioural science skills, for example, inter-

viewing, counselling and interpersonal skills, in their

day to day work in order to improve overall health

outcomes in primary healthcare.

Integrated primary mental health services are com-

plementary with tertiary and secondary level men-

tal health services (see the ‘optimal mix of services’

information sheet), e.g. general hospital services

(short stay wards, and consultation-liaison services

to other medical departments), which can manage

acute episodes of mental illness quite well but do not

provide a solution for people with chronic disorders

who end up in the admission–discharge–admission

(revolving door syndrome) unless backed up by

comprehensive primary healthcare services or com-

munity services.

Integrating specialised health services – such as

mental health services – into PHC is one of WHO’s

most fundamental health care recommendations.2

Rationale for integrating mental health services into primary healthcare

There are many advantages for integrating mental

health services into primary healthcare:

Reduced stigma for people with mental disorders and their families

Because primary healthcare services are not asso-

ciated with any specific health conditions, stigma is

reduced when seeking mental healthcare from a

primary healthcare provider (compared to a stand-

alone specialised service), making this level of care

far more acceptable – and therefore accessible – for

most users and families.

Improved access to care

Integrated care helps to improve access to mental

health services and treatment of co-morbid physical

conditions.

Comorbidity

Mental health is often comorbid with many physi-

cal health problems such as cancer, HIV/AIDS, dia-

betes and tuberculosis, among others. The presence

of substantial comorbidity has serious implications

for the identification, treatment and rehabilitation

of affected individuals. When primary healthcare

workers have received some mental health training

they can attend to the physical health needs of

people with mental disorders as well as the mental

health needs of those suffering from infectious and

chronic diseases. This will lead to better health

outcomes.

Improved prevention and detection of mental disorders

Primary healthcare workers are frontline formal

health professionals, ‘the first level of contact of

individuals, the family and community with the

national health system’.1 Equipping these workers

with mental health skills promotes a more holistic

approach to patient care and ensures both improved

diction and prevention of mental disorders.

Mental Health in Family Medicine 2008;5:9–13 # 2008 World Health Organization

What is primary care mental health?10

Treatment and follow-up of mental disorders

People who are diagnosed with a mental disorder are

often unable to access any treatment for their men-

tal health problems. By providing mental health

services in primary healthcare, more people will be

able to receive the mental healthcare they need

because of:

. better physical accessibility. Primary healthcare

is ‘the first level of contact (the closest and the

easiest to access) of individuals, the family and

community with the national health system’1

. better financial accessibility. When consulting

in hospitals, indirect health expenditures (trans-

portation, loss of productivity related to the time

spent in accompanying the patient to hospital,

etc) add to the cost of consultation and medi-

cations. If mental health services are integrated

into primary healthcare, healthcare costs are

greatly reduced/minimal . better acceptability. Linked to reduced stigma

and easier communication with healthcare pro-

viders (e.g. reduced language and cultural bar-

riers, better knowledge of the user’s personality

and personal and familial background/history).

Reduced chronicity and improved social integration, both for the people with mental disorders and his/her household

When people are treated far from their homes, it

disrupts normal daily life, employment and family

life; it removes individuals from their normal supports,

essential to recovery, and it imposes more burden on

families and care givers. By providing services in

primary healthcare the burden on individuals, families

and society will be reduced, household productivity

and social integration will be maintained, resulting

in better chances of recovery.

Human rights protection

. Providing treatment at primary healthcare, backed

by secondary health care and informal commu-

nity care can prevent people from being admitted

into psychiatric institutions often associated with

human rights violations. . The reduced stigma associated with receiving care

in primary healthcare settings can also mean

people with mental disorders and their families

are less likely to experience discrimination within

society.

Better health outcomes for people treated in primary healthcare

In terms of clinical outcomes it has been found that,

for most common mental disorders, primary health-

care can deliver good care and certainly better care

than that provided in psychiatric hospitals.

Improving human resource capacity for mental health

Integrating mental health services into primary

healthcare can be an important solution to address-

ing human resource shortages to deliver mental

health interventions.

Challenges to overcome for successful integration

Integration of mental health services requires a lot of

careful planning and there are likely to be several

issues and challenges that will need to be addressed.

For example:

. integration into primary healthcare requires in-

vestment in the training of staff to detect and

treat mental disorders . within the context of training, primary health-

care workers may be uncomfortable in dealing

with mental disorders and may also question their

role in managing disorders. Therefore, in addition

to imparting skills, training also needs to address

the overall reluctance of primary healthcare

workers to work with people with mental dis-

orders . the issue of availability of time also needs to be

addressed. In many countries primary health-

care staff are overburdened with work as they

are expected to deliver multiple healthcare pro-

grammes. Governments can not ignore the need

to increase the numbers of primary healthcare

staff if they are to take on additional mental

health work . adequate supervision of primary care staff is

another key issue which needs to be addressed

if integration is to succeed. Mental health pro-

fessionals should be available regularly to pri-

mary care staff to give advice as well as guidance

on management and treatment of people with

mental disorders. Furthermore the absence of a

good referral system between primary and second-

ary care can severely undermine the effectiveness

What is primary care mental health? 11

of mental healthcare delivered at primary health-

care level . finally, governments must pay attention to key

human resource management issues in primary

healthcare – adequate working conditions, pay-

ment, resources and support to carry out de-

manding work.

WHO key recommendations for integration

Preliminary situational analysis

Integration requires a careful analysis of the best

options for the treatment and care of mental dis-

orders at different levels of care (see Figure 1). The

specific ways in which mental health should be

integrated into primary healthcare will be influenced

by the current function, status and strengths of

primary, secondary and tertiary care levels within

countries’ existing health systems as well as the

community context.

Build one existing networks/structures and human resources

As far as possible, and as long as consistent with the

international standards of good practices, countries

must look at using and strengthening existing net-

works of services, including those in primary health-

care, to provide mental health services.

Figure 1 Rationale for integrating mental health services into primary healthcare

What is primary care mental health?12

Funding

Funds must be shifted/redistributed from tertiary to

secondary and primary levels of care (and/or com-

munity oriented mental health services), or new

funds must be made available.

Clear delineation of mental disorders

The delineation of a few targeted mental disorders to

be treated at the primary care level in some contexts

can be desirable. It simplifies both the requirements

for types of medicine (limited list of psychotropic

medications) and the training of primary care workers

who then need to be proficient and skilled in the use

of a few selected drugs. The range of disorders can be

increased in a stepped manner according to capacity

and needs.

Human resource training and competencies

Integration into primary healthcare requires train-

ing of primary care staff in identification and treat-

ment of mental disorders. The training of established

primary care teams should occur in service settings

and should involve programmes in diagnosis, man-

agement, and follow-up consultations as well as

human rights and family intervention.

General health staff must have the knowledge,

skills and motivation to treat and manage patients

suffering from mental disorders. A mental health

component should be included in the educational

curriculum of all social and health workers and

ongoing training and support provided on site.

Recruitment/education of new PHC staff

In some countries, primary care staff are already

overburdened with work and integration of mental

healthcare into primary healthcare will require and

increase in the absolute numbers of primary care

staff. There need to be sufficient numbers of staff with

the knowledge and authority to prescribe psycho-

tropic medicines at primary and secondary levels.

Availability of medicines

Basic psychotropic medicines must be available at

primary and secondary care levels. Governments

need to ensure that sufficient funds are allocated

to purchase the basic essential psychotropic medi-

cines and make sure they are available in primary

care settings, in accordance with the policy adopted.

Medicines may be purchased under generic names

from non-profit organisations, allowing access to

drugs of good quality at low prices.

Supervision and support of primary healthcare staff

Primary healthcare staff have to be adequately super-

vised, monitored and supported by mental health

specialists (professional at/of secondary level) if

integration is to succeed. The mental health pro-

fessional should be available to discuss difficulties in

management and to provide advice on interven-

tions to be carried out by primary care staff.

Effective referral system and coordination of a collaborative network

Effective referral links between primary, secondary

and tertiary levels of care need to be in place. It is

recommended to develop and coordinate a collab-

orative network in order to provide mental health

services.

Intersectoral approach and links with community services, both formal and informal

An intersectoral approach and collaboration will

enhance the success of a primary healthcare approach

– collaboration with non-health sectors such as

education, social welfare, justice or employment/

labour both at the policy, the planning and the

implementation/service levels will be required.

. Many mental disorders require psychosocial sol-

utions. Thus, links need to be established between

mental health services and various community

agencies at the local level so that appropriate

housing, income support, disability benefits, em-

ployment, and other social service supports are

mobilised for people with mental disorders and

in order that prevention and rehabilitation strat-

egies can be more effectively implemented. . Close links with the informal community ser-

vices is also fundamental – NGOs, religious

leaders and other systems of support – and will

lead to better outcomes and rationalisation of

resources.

What is primary care mental health? 13

Recording systems for evaluation and monitoring

Recording systems need to be set up to allow for

continuous monitoring, evaluation and updating of

mental health activities: mental health data need to

be routinely recorded in patients’ files and integrated

in the overall general health information system at

primary healthcare level, in order to be used for

monitoring, evaluation and planning and service

improvements.

REFERENCES

1 WHO. Declaration of Alma-Ata. International Con-

ference on Primary Health Care, Alma-Ata, USSR, 6–

12 September, 1978. www.who.int/hpr/NPH/docs/

declaration_almaata.pdf (accessed 25 April 2007).

2 WHO. The World Health Report 2001. Mental Health:

New Understanding, New Hope. Geneva: World Health

Organization, 2001 www.who.int/whr/2001/en/whr01

_en.pdf (accessed 23 April 2007).