Primary care and mental health: how can the world respond?
Almost all interested parties have endorsed the view that there should be close integration between primary care, in its various manifestations and organisations worldwide, and mental health. The reason is built on well rehearsed arguments of the interdependence of all kinds of diseases and the striking comorbidity between mental health and other diseases. Traditionally physical health and mental health have been divided both in education and in practice. Over recent decades attempts have been made to address this problem both at the educational level and in the organisation of services. There have been some good examples of how this has been achieved but, notably, advances have been both slow and hesitant. The divide between primary care and mental health has in some services been bridged by psychiatrists treating psychiatric outpatients in primary care settings. This has tended to improve communication and understanding but has proved costly in time and travel. It is generally recognised that as most people attend primary care facilities they should be able to seek help for mental health problems there free from the stigma and fear which is associated with the many mental hospitals which still exist throughout the world. There also seems to be general agreement that in primary care first line diagnoses should receive treatment whatever the illness may be. Primary care workers are best placed to consider issues surrounding patients, their families and the local workplace, and have knowledge of past illnesses. Most patients with mental health problems can be treated adequately in primary care, which should also be an important source of referral to secondary care, where the early treatment of psychotic illness is required to prevent chronicity. The primary care workers are in the best position to understand the procedures required for achieving full recovery and the patient's return to normal life and work. If most of this is generally agreed, why has movement towards this ideal been slow? It has to be said that in many parts of the world, doctors now receive a reasonable proportion of their training in mental disorders but that comorbidity with other disorders is still little understood. Psychiatrists tend to see patients who have been treated successfully for the surgical effects of serious accidents late in their recovery because their clinical colleagues in other specialties have not recognised the important psychological consequences, which in the end are the main factors for delayed recovery and return to work. In many parts of the world primary care is delivered through polyclinics where there is no emphasis on or even understanding of mental comorbidity. Most frequently in these circumstances those persons seeking help for mental health problems must attend the local mental hospital. Reluctance by clinicians to change, especially where mental hospitals have become family owned businesses, presents a particular problem. Even in the best medical schools medical students may quickly learn that reporting mental health problems to older colleagues is not greeted with appreciation. Psychiatrists, because they are in frequent contact with mental illness, tend to believe that its recognition is simple but they may be mistaken. Most psychiatrists would admit that a full psychiatric examination of the patient even for relatively minor mental health problems can take a substantial period of time. Primary care physicians with serious time constraints can hardly be expected to give that time to individual patients and so decisions may have to be made following very short enquiry and observation, leading in many cases to unnecessary pharmaceutical treatment or to serious, partially disguised illness being missed and sometimes progressing to suicide. How are these matters to be tackled? It may not be feasible to expect improvements to come through education. In many countries there are very inadequate psychiatric services. In some countries there are no psychiatrists and very few psychiatric nurses. Many of those locally trained emigrate to other wealthier parts of the world to improve their standard of living. Their education has been expensive in both money and time. The only solution at present may lie in the development of new technologies to give primary care workers skills in the detection of mental illness. Computer methods have now been tested which can be used much as an X ray or a blood test might for those thought to be suffering from chest or other physical illnesses. Briefly trained primary care workers can administer a 15 minute interview covering basic mental health symptoms, from which a computer can be shown to provide a reliable and valid diagnosis followed by recommendation of treatment strategies. Similar but more extensive methods for use where there are no psychiatrists to provide secondary care are now being validated. Such instruments could revolutionise the ability to treat the half of the world's population that currently has no prospect of mental illness treatment either in primary or secondary care.1 There are, however, still more barriers. The Lancet call laid out clear evidence for the need to address mental health problems not only to improve the health of the world population but also to improve its economic performance.2 A number of reports have emerged across the world over the last decade emphasising the same message that the treatment of mental disorders is of vital importance to human well being, to economic progress and to the fulfilment of the human right to be relieved of suffering. The assumption that such evidence would be seized and acted upon by governments may have been naive. Politicians who seek election are guided by short term successes. Politicians who are not elected have other interests. Small incremental changes may have taken place in some localities but in general there has been little discernible response. Is there nothing that can be done? There is talk of the importance of advocacy, but is talk sufficient? There are two outstanding needs that those who would promote mental health must recognise. The first is that they should dispel the perception of disunity and disharmony in what they recommend and in what they believe. Such disunity is probably considerably exaggerated, often by those who are unwilling to change. The demonstration of 'unity' on the basic beliefs of the mental health world community is very important. The World Federation for Mental Health has started a consensus survey to demonstrate that there is substantial agreement across the world on what the community expects governments to undertake. The second most important aspect of advocacy is 'visibility' Mental disorders by their nature lack such visibility and those who suffer from them often feel stigmatised. If the mental health community does not achieve more visibility for what it believes is right then it is unlikely to succeed. The World Federation for Mental Health (WFMH) advocates on its website that all those who believe that mental health should be elevated on government agendas should contribute to better visibility. Many bodies organise rallies and parades for World Mental Health Day. Such expressions of support do not come easily to many of us but in other areas they have achieved notable successes. Not all countries allow public demonstrations of support of course, but where they do we hope that the public will come out in force on 10 October each year to join with millions of others around the world to demonstrate to governments that we are visible, that we march together with consumers, families, doctors, social workers, nurses, other health workers and all those who celebrate good mental health and require that mental illness be properly recognised and treated. World Mental Health Day 10 October 2009 is particularly concerned with primary care and mental health. The WFMH hopes to demonstrate that unity exists, that we are also visible and to demand that governments respond. Is there any other way in which we can achieve action to promote the basic human right to relieve suffering and promote the recovery of our fellow human beings?
Mental health in family medicine