MANAGEMENT OF MENTAL HEALTH DISORDER: Primary Care Setting

Joko Mulyanto Department of Public Health & Community Medicine Faculty of Medicine and Health Sciences Jenderal Soedirman University

SIGNIFICANCE of MENTAL HEALTH DISORDER

High prevalence, great burden, minimal resources. Global life time prevalence ranges from 12.2 48,6 %, while annual prevalence ranges between 8.4 29.1%. Higher prevalence in low-income countries. Most common are anxiety and depression. Strongly correlated with suicide 14 % of global burden of disease

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WHO estimated that in 2030, unipolar depressive disorder is second highest single cause of global burden of disease (currently is 4th). 35 % population in developed countries with serious mental disorder receive no treatment, while the number in less-developed countries range from 75 -85 % Inadequate professional human resources, and allocation of financial resources.

WHY SHOULD INTEGRATE MENTAL HEALTH INTO PRIMARY HEALTH CARE?

The burden of mental health disorder is great. Mental and physical health problems are interwoven The treatment gap is significant Enhance access Respect human right Affordable and cost effective Generate good outcomes

COMMON MENTAL DISORDERS IN PRIMARY HEALTH CARE

Anxiety, depression, and somatisation Mild to moderate severity (non-psychotic) Significant disability Co-morbidity with chronic health condition Co-morbidity with substance abuse Psychosocial problems.

WHAT IS PRIMARY HEALTH CARE ?

Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health-care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Encompassing interventions that take place in community settings, involving families and communities (including through outreach services such as those provided by community health workers) and those offered at first-level health facilities, together with mechanisms to improve continuity of care at this level.

PRIMARY MENTAL HEALTH CARE

Integration of mental health into primary health care. Horizontal integration Vertical integration To provide holistic and continuous care within and between level of care To improve the recognition and treatment of common mental disorders at primary level.

INTEGRATION ASPECTS OF PRIMARY MENTAL HEALTH CARE

Package of care: what specific services are provided Location of services : first line, formal services, community outreach Staffing: generalist, or professional mental health

TYPICAL MODEL OF PRIMARY MENTAL HEALTH CARE

Mental health in primary care Mental health at primary care Mental health community outreach Mental health care provided through other sectors

MENTAL HEALTH IN PRIMARY CARE

Primary mental health care is part of primary health care generalist services. Full integration with primary level general health care services with staffing by generalist health workers as part of their routine function. Staffing for mental health care is provided by generalist staff (doctor or nurse). Staff receive training and supervision in mental health from mental health professionals based at a secondary or tertiary level

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The package of care generally includes identification, assessment (diagnosis and determination of severity and impairment) and treatment of CMD, and prescription of psychotropic medication . The use of formal screening instruments, used routinely to assist in identification Various counseling and psychotherapeutic interventions are increasingly being incorporated into the care package Referral for specialist care or other services following standard referral pathways and procedures may be arranged. In some instances medical treatment started by a practitioner operating at a secondary level may be continued by a primary care health worker.

MENTAL HEALTH AT PRIMARY CARE

It is located on-site at (but not integrated with) primary level general health care services Staffing by specialist mental health practitioners (whether professional or auxiliary workers). Mental health care is provided at the site of firstline health care (a clinic or health post) Mental health professionals, usually nurses with mental health training or psychiatric specialization, but sometimes psychologists

 Identification and initial assessment of mental disorder would usually be undertaken by a generalist health worker The patient referred for confirmation of diagnosis and treatment to the mental health practitioner. Where patients self-identify a mental health problem, they may be permitted to see the mental health practitioner directly Treatment offered by the mental health practitioner varies depending on level of worker, professional background and mental health training Include informal or more formal counseling or psychotherapeutic interventions (individual, family or in a group), prescription or dispensing of psychotropic medication and case management. Where necessary, referrals to secondary or tertiary level care are arranged.

MENTAL HEALTH COMMUNITY OUTREACH

Mental health care is provided in community settings by staff based in the community or operating on outreach from a health service Community/village health workers or other health workers based within the community can play an important role in identifying, supporting and referring people for more specialized mental health care. With some mental health training, they can assist and understand when someone needs referral to a health practitioner Workers based in the community can also visit patients that have defaulted or not attended the clinic/health post for mentalhealth care as expected. This can be extremely useful in reducing patient relapse.

MENTAL HEALTH CARE PROVIDED THROUGH OTHER SECTORS

Mental health care provided usually by non healthcare organization For special occasion, such as natural disaster, criminal victim. Provide usually some aspects of primary mental health care. Staffing may be generalist staff (social worker, police officer), volunteer counselor, on-site or on-call mental health professional.

HOW TO IMPROVE PRIMARY MENTAL HEALTH CARE

Screening Assessment Psychotropic medication Counseling Psychotherapeutic intervention Organization of care

SCREENING
Development of screening tools for common mental disorder Improve rate of identification CMD by generalist health worker. Screening focus on population at risk Various tools have been developed, usually short screening questionnaire.

ASSESSMENT
Process to interpret screening into diagnosis and severity/level of impairment. Conducted by competent health practitioner, different with screening which can be conducted by auxiliary worker Diagnosis made based on formal psychiatric diagnosis such as DSM-IV, ICD 10. Followed by treatment (intervention).

PSYCHOTROPIC MEDICATION
To be effective, psychotropic medication must be taken at adequate dose levels and for an adequate duration Adequacy in number and type of psychotropic drugs (minimum essential psychotropic drugs). Prescribing guideline Case management: follow up, treatment adherence. Acceptable drugs: once daily dosage, minimal adverse effect, minimal interference with everyday life, low interaction with food or drugs.

COUNSELING
Non-medical interventions that are usually fairly limited in duration (generally not more than 68 sessions, but in some cases one session only) and scope (generally aimed at managing symptoms rather than more significant changes). It may be structured (e.g. with regard to content and number of sessions) and at times directive. It may be conducted by staff with limited or no mental health training and only limited if any training in counseling specifically

INFORMAL COUNSELING
Refers to counseling that may occur in the context of a health consultation. Lack of purpose due to variability of staff ability, consultation time, perception of biomedical model.

PSYCHOEDUCATIONAL COUNSELING
Counseling which focuses primarily on providing relevant information (for example, regarding symptoms, the role of related factors such as stress, coping strategies) and helping patients to apply the information in their own situation, for example, to recognize the onset of symptoms or stress factors and tailor stress management techniques to deal with these. Evidence showed that its ineffective

PSYCHOTHERAPEUTIC INTERVENTION
Psychological interventions that have an explicit theoretical base that (even in the case of brief forms of a therapy) tend to be longer in duration (number of sessions and time period) than counseling and that require specific training of practitioners in that model Cognitive-behavior therapy Interpersonal psychotherapy

ORGANIZATION OF CARE
Referral system: Horizontal and vertical. Case management: assigning responsibility for overseeing and coordinating the care of a patient to a particular member of the health care team. Stepped care: involving provision of low intensity interventions to a significant proportion of patients who nevertheless derive significant benefit from these interventions; more intensive interventions (including referral for specialist care) are then restricted to patients who have more severe disorder or who fail to improve

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Collaborative care: is a way of organizing care that is directed at more efficient use of resources and more effective care for patients

THANK YOU
jokomulyanto2011