YPMED-04153; No of Pages 7 Preventive Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Review
Is there a case for mental health promotion in the primary care setting? A systematic review Ana Fernandez a,b,c,j,⁎,1, Patricia Moreno-Peral c,d, Edurne Zabaleta-del-Olmo c,e,f, Juan Angel Bellon c,d,g, Jose Manuel Aranda-Regules c,d,h, Juan Vicente Luciano b,c,i, Antoni Serrano-Blanco b,c, Maria Rubio-Valera b,c,i,1 a
Centre for Disability Research and Policy/Brain and Mind Research Institute, Faculty of Health Sciences, University of Sydney, Australia Research and Development Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain Network for Prevention and Health Promotion in Primary Care (RedIAPP, ISCIII), Spain d Instituto de Investigación Biomédica de Málaga (IBIMA), Unidad de Investigación del Distrito de Atención Primaria de Málaga, Spain e Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Barcelona, Spain f Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain g Centro de Salud El Palo, Distrito de Atención Primaria Málaga-Guadalohorce, Departamento de Medicina Preventiva, Universidad de Málaga, Spain h Centro de Salud San Andrés Torcal, Distrito Sanitario Málaga-Guadalhorce, Servicio Andaluz de Salud, Málaga, Spain i Open University of Catalonia, Barcelona, Spain j Department of Pharmacology and Therapeutic Chemistry, School of Pharmacy, Universitat de Barcelona, Spain b c
a r t i c l e
i n f o
a b s t r a c t
Available online xxxx
Objectives. To evaluate the effectiveness of mental health promotion (MHP) interventions by primary health care professionals in the adult population. Methods. Systematic review of literature in English and Spanish for randomized controlled trials (RCTs) and observational studies evaluating the impact of interventions carried out by primary care professionals explicitly to promote and improve the overall mental health of adult patients. PubMed, PsycINFO, and Web of Science were independently searched by two investigators to identify all MHP articles from inception to October 2013 (no restrictions). Results. We retrieved 4262 records and excluded 4230 by a review of title and abstract. Of 32 full-text articles assessed, 3 RCTs were selected (2 in USA, 1 in UK); two focused on the mental health of parents whose children have behavioral problems, the other on older people with disabilities. One study reported a MHP intervention that improved participants' mental health at 6-month follow-up. All studies had low-moderate quality (2 of 5 points) on the Jadad Scale. Conclusion. There is a lack of implementation and/or evaluation of mental health promotion activities conducted by primary care professionals. More research is needed to clearly understand the benefits of promoting mental health in this setting. © 2014 Published by Elsevier Inc.
Keywords: Health promotion Mental health Primary health care Systematic review
Contents Introduction . . . . . . . . . . Method . . . . . . . . . . . . Literature search . . . . . . Study selection . . . . . . Eligibility criteria . . . . . . Population/promotion Intervention . . . . Comparison . . . . . Outcomes . . . . . .
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⁎ Corresponding author at: Centre for Disability Research and Policy — Brain and Mind Research Institute, Faculty of Health Sciences T432a Cumberland Campus, The University of Sydney, 75 East Street, Lidcombe, NSW 2141, Australia. Fax: +61 2 9351 9566. E-mail address: [email protected] (A. Fernandez). 1 Ana Fernandez and Maria Rubio-Valera contributed equally to this work.
http://dx.doi.org/10.1016/j.ypmed.2014.11.019 0091-7435/© 2014 Published by Elsevier Inc.
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
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Risk of bias in individual studies . . . Data extraction . . . . . . . . . . . Synthesis of results . . . . . . . . . Results . . . . . . . . . . . . . . . . . Literature search and study selection . Characteristics of the included studies Risk of bias . . . . . . . . . Description of interventions . . Mental health outcomes . . . Discussion . . . . . . . . . . . . . . . Limitations and strengths . . . . . . Conclusion . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . Funding . . . . . . . . . . . . . . . . Appendix A. Supplementary data . . . . References . . . . . . . . . . . . . . .
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Introduction Mental Health has been defined as ‘a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ (WHO, 2010). Therefore, the promotion of good mental health is critical not only for the person, but also for society. People with poor mental health have lower life expectancy. This difference is explained both by suicide rates and by the higher prevalence of chronic medical conditions (e.g., cardiovascular disorders, cancer) in this population (Lawrence et al., 2013). In addition, mental disorders are associated with high disability and related costs for society, a substantial proportion of which are due to absences and loss of productivity (Bloom et al., 2011), as well as to earlier retirement of withdrawal from the workforce (Mcdaid and Park, 2011). With the increasing recognition of the burden associated with mental illnesses (Whiteford et al., 2013), there has been a rise in research on mental health promotion (MHP). In 1996, MHP was defined as ‘the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health. Mental health promotion uses strategies that foster supportive environments and individual resilience, while showing respect for culture, equity, social justice, interconnections, and personal dignity’ (Joubert et al., 1996). Five years later, the World Health Organization (WHO, 2001) described MHP as “(…) an umbrella term that covers a variety of strategies all aimed at having a positive effect on mental health. The encouragement of individual resources and skills and improvement in the socioeconomic environment are among them”. Both definitions suggest that MHP requires initiatives both at macro level (e.g., policies leading with inequity and promoting social justice) and micro level (e.g., individual interventions). Although MHP and health promotion share the values presented in the Ottawa Charter (1986), there are two major differences. First, MHP directly aims to increase resilience and empower people, by increasing their ability to cope with significant adversity or stressful life events (CAMH, 2010). Second, MHP targets the cognitive, social, and emotional skills (e.g., problem solving, social skills, and social support), while health promotion is focused on lifestyle factors (e.g., promotion of physical activity and healthy eating and reduction of smoking and drinking behaviors). It is important to highlight that these approaches are complementary: healthy lifestyles increase mental wellbeing (Penedo and Dahn, 2005), and by improving emotional wellness we also improve physical health (Wiest et al., 2011). MHP also differs from primary prevention of mental disorders. Primary prevention focuses on reducing or eliminating the risk factors for a specific pathology. In contrast, MHP targets a broad variety of problems and focuses on the positive factors (Stachtchenko and Jenicek, 1990). However, the two approaches overlap and are interrelated,
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making it difficult to separate them in day-to-day practice. It is known that multiple risk and protective factors are involved in the onset of mental disorders; therefore, most initiatives designed to prevent specific mental disorders also include strategies to improve the protective factors. The main difference, then, is in the final aim: MHP aims to enhance overall wellbeing, not to “fight” against a specific disease (Min et al., 2013; Saxena and Maulik, 2002; Stachtchenko and Jenicek, 1990; WHO, 2004). Finally, MHP differs from therapeutic interventions because it targets the general healthy population, while treatment focuses on people who are already ill. Although people with mental disorders may be able to benefit from MHP initiatives, this population is not the main target of these strategies (Min et al., 2013; Saxena and Maulik, 2002; Stachtchenko and Jenicek, 1990; WHO, 2004). In summary, MHP has a primary preventive component (i.e., the main target is the healthy people), but focuses on positive aspects of mental wellbeing. It is valued to separate prevention and promotion strategies in the field of mental health, because it facilitates giving adequate attention to both, and it is easier for decision-makers to evaluate the results of the programs (Saxena and Maulik, 2002). The effectiveness of MHP interventions has been well documented in school settings (Barry et al., 2013; Evans et al., 2005; Franze, 2004; Michaelsen-Gartner and Witteriede, 2009; Mishara and Ystgaard, 2006; Roberts et al., 2003; Weare and Nind, 2011), at the workplace (Czabala et al., 2011; Lerner et al., 2013; Mattke and Van Busum, 2013; Patel et al., 2013; Sun et al., 2013; Torp et al., 2013; Tsutsumi et al., 2009), and in community centers serving older adults (Chapin et al., 2013; Forsman et al., 2011; Ichida et al., 2013). This is in line with the results of a recent systematic review (Mcdaid and Park, 2011) and a report presenting different economic models for mental health promotion and prevention (Knapp et al., 2011). Both documents concluded that there is a case for some interventions to promote mental health and wellbeing in some very specific contexts and settings. However, just one of the contexts analyzed in these documents included primary care centers, and it was for alcohol misuse. In theory, primary health care centers are, well positioned within the community to perform the MHP activities. Primary care is in the “front lines” of health care delivery and serves as the primary point of contact for most individuals in most health systems. This venue is therefore among the most accessible in health care and likeliest to reach a larger swath of the population. Equipping these professionals with mental health skills promotes a more holistic and integrated approach and ensures not only improved detection and treatment, but also prevention of mental disorders and promotion of mental health and wellbeing (WHO, 2008). The role of primary health care professionals dealing with mental disorders have been highlighted in different reviews, concluding that primary health care providers can treat common mental disorders, specially depression (Gerrity et al., 2004; Gilbody et al., 2003; Gunn et al., 2006; Woltmann et al., 2012); however, as we
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
A. Fernandez et al. / Preventive Medicine xxx (2014) xxx–xxx
have already stated, little is known about MHP delivered at primary care centers by primary health professionals. This systematic review is part of a series of reviews aiming to establish the evidence base for the promotion of different healthy behaviors, the prevention of cardiovascular diseases, and the prevention of depression and anxiety at the primary health care level. All this information was combined to design a complex intervention for dealing with multiple risk factors in order to prevent multimorbidity, which is currently a hot topic in primary care (Smith et al., 2012). The inclusion of interventions to promote overall mental health (and not just preventing specific conditions) fills a gap and provides a more holistic view. To the best of our knowledge, this is the first review to evaluate the effectiveness of MHP interventions delivered by primary health care professionals to their adult patients. Method We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (Moher et al., 2009). Literature search We performed a systematic review of the published literature for randomized controlled trials (RCTs) and observational studies evaluating the impact of interventions made by primary health care professionals (general practitioner, nurses, and social workers) explicitly aiming to promote and improve the overall mental health of adult patients. The PubMed, PsycINFO, and Web of Science datasets were independently searched by two investigators (AF and MRV) to identify all articles involving MHPs. We completed literature searches from database inception to October 2013, with no restrictions, using free text and controlled vocabulary terms. The search strategies used can be consulted in Supplemental file 1. Titles and/or abstracts of all citations were obtained for study selection. Reference lists of retrieved articles were checked for additional studies not identified in the original database search. Expert informants from the Primary Care Prevention and Health Promotion Research Network REDIAPP (www. rediapp.org) were consulted to retrieve gray literature (such as unpublished reports and conference abstracts). One of the reviewers (AF) also searched the Cochrane Library and the “International Journal of Mental Health Promotion”, a key journal not indexed in the databases used. Study selection Studies were screened for inclusion in two phases and the entire process was carried out in duplicate (AF and MRV). In phase 1, records were selected by reviewing the title and/or the published abstract. In phase 2, the full-text article was reviewed. In case of any disagreement, researchers discussed the problems, trying to reach a consensus. When a consensus was not reached, a third co-author read the paper. Eligibility criteria Population/promotion As discussed in the Introduction, the MHP concept has the problem of not being very specific. If we include all the strategies that have a positive effect on mental health, we would have to include all activities ranging from the prevention of mental disorders to their treatment. This review focused only on those MHP interventions that targeted mainly healthy people. The reviews focused on the effectiveness of MHP interventions usually exclude those delivered to people diagnosed with mental disorders (Mcdaid and Park, 2011). Therefore, we included only those interventions conducted with adult (N17 years old) primary care patients with no such diagnosis at the time of the study. Intervention We only included interventions whose primary objective was to improve participants' mental health by increasing their ability to cope with daily stressors. Daily stressors are defined as routine challenges of day-to-day living, such as the everyday concerns of work, caring for other people, and commuting between work and home. They may also refer to more unexpected small occurrences—such as arguments with children, and unexpected work
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deadlines—that disrupt daily life (Almeida et al., 2002). Activities such as problem-solving techniques, cognitive restructuring, relaxation, and interventions to increase self-esteem, resilience, and/ or self-efficacy were included. In consequence, we excluded those health promotion interventions (such as promotion of physical activity or healthy diet) that included mental health outcomes as a secondary aim, but were not focused on life skills. We were interested in interventions delivered by the key professionals that are common across different primary health care systems (general practitioners or family physicians, primary care nurses, and social workers). This definition excluded all studies in which the role of the primary health care professional was limited to the referral of participants to specialized or social services without any additional involvement. The impact of social prescribing or community activities on overall wellbeing can be seen elsewhere in the supplement. Comparison We included those studies that compared MHP interventions with the usual care. Outcomes Any global measure of mental wellbeing, mental health, wellness or mental health related quality of life was included. Studies using condition-specific measures (such as depression or anxiety) are reviewed elsewhere in the supplement. To focus on the most up-to-date information and ensure that the researchers had access to a formal definition of MHP (Joubert et al., 1996), we excluded those papers written before 1997. Only papers written in English or Spanish were considered. Risk of bias in individual studies The quality of the selected studies was assessed independently by AF and MRV using the Jadad (Jadad et al., 1996) scale, which considers 3 features of a study: randomization, double-blinding, and flow of patients. Scores range from 0 to 5, with the higher scores indicating higher quality. If we had included any observational study, we would have used the list of quality criteria suitable for evaluating this type of studies (Mallen et al., 2006). However, none of the papers included was an observational study. Data extraction Two reviewers (AF and MRV) independently extracted key features of the characteristics, methods, and outcomes of articles that met the inclusion criteria. The key features included study design, period of study, setting, sample size, primary care professionals involved, intervention components, the main outcome measures reported by the authors, results, and conclusions. In the case of disagreement, researchers reviewed the data looking for a consensus. A third reviewer (PMP) also checked the data. Synthesis of results Due to the small number of studies selected, their clinical heterogeneity, and their low quality (see Results), we decided not to combine data.
Results Literature search and study selection The electronic search strategy identified 5633 records, while 29 trials and 2 systematic reviews were retrieved via the Cochrane Library. Using the search engine at the “International Journal of Mental Health Promotion”, AF also retrieved 166 records that included anywhere the words “primary care”. After removing all records previous to 1997 and those that were duplicated, 4262 were reviewed. A total of 4230 were excluded by reviewing title and abstract. Of the 32 full-text articles assessed for eligibility, 3 were selected by both researchers, 24 were excluded by both, and both authors had doubts about 5 articles. Both researchers, in collaboration with other co-authors, reviewed and discussed those papers, finally agreeing to exclude them (Fig. 1).
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
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Fig. 1. Flow diagram of the study inclusion process.
Characteristics of the included studies We identified 3 studies for inclusion in this systematic review (Friedman et al., 2009; Patterson et al., 2002; Wissow et al., 2008). Table 1 summarizes the main characteristics of these studies. Two of the studies were conducted in USA (Friedman et al., 2009; Wissow et al., 2008) and one in UK (Patterson et al., 2002). The studies were conducted between 2002 and 2009. Regarding the type of study sample, that of Friedman et al. (2009) was conducted in elderly Medicare beneficiaries with disabilities, while the other 2 studies focused on the mental health of parents whose children have mental or behavioral problems (Patterson et al., 2002; Wissow et al., 2008). The primary care professionals who delivered the interventions were nurses (Friedman et al., 2009; Patterson et al., 2002; Wissow et al., 2008) and family physicians (Wissow et al., 2008). All 3 studies were RCTs and the comparator was usual care. Two of them stated that they analyzed the data according to intention-totreat (Patterson et al., 2002; Wissow et al., 2008) although they did not explain how they handled dropouts and missing data.
Risk of bias Methodological quality scored 2 out of 5 (low-moderate) in all 3 papers. Just one paper generated discrepancies between the 2 researchers (AF and MRV) that were discussed until reaching a consensus. The main problems of the paper by Friedman et al. (2009) were related to an inadequate explanation of randomization, and the fact of not being blinded. However, the blinding of participants is very difficult in this
type of interventions. The problems of the paper by Patterson et al. (2002) were also related with blinding and a lack of complete explanation of withdrawals. Finally, the paper by Wissow et al. (2008) was limited by an inadequate explanation of the randomization process and of dropouts and withdrawals. By contrast, in this study both assessors and patients were blinded to the intervention. Description of interventions The intervention tested in the paper by Friedman et al. (2009) was based on the PRECEDE health education planning model. The nurses made home visits an average of once a month during 22 months (mean number of visits, 19; standard deviation (SD) 1). During those visits they reviewed medications but also tried to empower the patients by educating them in how to better manage their chronic diseases. The intervention tested by Wissow et al. (2008) was a training program in mental health care interventions for primary care practitioners (from different types of community centers). The rationale behind this intervention was that once professionals were trained, they could have the skills to educate their patients on how to deal with their problems. The provider training was based on active learning and locally relevant content. It consisted of 3 sessions. The skills trained were related to solution-focused cognitive therapy, motivation, and family engagement. On the other hand, the paper by Patterson et al. (2002) evaluated the impact of the Webster-Stratton Parents and Children Series. The intervention consists of 10 weekly sessions, each about 2 h long and led by a home health visitor and either a second home health visitor or a nurse. The activities carried out during the sessions include video
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
Study
Friedman USA et al. (2009)
Wissow et al. (2008)
% of Women (C/I)
Mean age (C/I)
Design Follow-up (in months)
Description of the intervention
766 (384/382)
68.8 (69.5/68.1)
77.3 (77.5/77.2)
RCT
11 nurses After an initial home assessment visit, the nurse made home visits an average of once a month. In these visits, she reviewed the patient's medications and used the theoretical models of the PRECEDE health education planning model to help address disease prevention, health promotion, chronic disease self-care and self-management, and health behaviour change and maintenance.
418 families (170/248)
90.7 (89/92)
37.6 (SD9.5)/36.8 (SD7.6)
Cluster RCT
6
116 parents (56/60)
Not provided
Not provided
Block RCT
6
Country Sample (C/I)
USA
Patterson UK et al. (2002)
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The training contained communication skills that built on providers' existing knowledge of child behaviour and development. Skills were drawn from patient-centered care, family therapy, solution-focused cognitive therapy, motivational enhancement, and family engagement. Training was delivered in 3 cycles, spaced 3 weeks apart. Each cycle began with a 60-min, small-group discussion, held on-site during work hours and led by a child psychiatrist. The discussion used a computerized slide set containing background material, written and video examples of skills, and programmed pauses for interaction. The intervention comprised sessions lasting about 2 h each, once a week for 10 weeks. The activities included video vignettes of parent–child interactions, group discussion, role-play, rehearsal of parenting techniques, and home practice. The techniques covered included play and positive interaction with the child, clear commands, limit setting, ignoring undesirable behaviour, praising and rewarding desirable behaviour, and following through on discipline.
Professionals involved in the Intervention
48 physicians, 9 nurse practitioners, and 1 physician's assistant, from different sites (urban and rural community base)
Main mental health measure
Differences
General self-efficacy; health self-efficacy; internal health locus of control scale; powerful others health locus of control scale; chance health locus of control scale; mental health component summary (SF-36); activities of daily living: instrumental activities of daily living
Adjusted results at 20 months (β; SE; p value) general self-efficacy (−0.01;0.27; 0.96); health self-efficacy (−0.25;0.22; 0.26); internal health locus of control scale (−0.37;0.,35,0.29); powerful others health locus of control scale (−0.26;0.38;0.50); chance health locus of control scale (−0.33;0.42;0.43) mental health component summary (SF-36) (0.81;0.85,0.34); activities of daily living-dependence (-0.25;0.12,0.04*); instrumental activities of daily living-dependence (0.16;0.12,0.18) Seeing a trained provider was associated with a significantly greater decrease (on average −1.7 GHQ points; 95% CI −3.2 to −0.11; p = 0.035: effect size 0.31)
General Health Questionnaire (GHQ): the Parenting Stress Index (PSI) and the Self Esteem Scale
General Health Questionnaire Each group was run by at least one health visitor with (GHQ): the Parenting Stress Index either a second health visitor (PSI) and the Self Esteem Scale or a nursery nurse as co-leader in 3 general practices in Oxford
A. Fernandez et al. / Preventive Medicine xxx (2014) xxx–xxx
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
Table 1 Summary of the papers included in this review.
Means (SD) at baseline and 6 months follow-up by group (C/I) and p value: GHQ: C 4.3 (4.9)/3.0 (4.6) vs I 5.1 (4.9)/2.7 (4.2); p = 0.24; PSI: C 86.5 (18.4)/83.4 (17.0) vs I 85.0 (20.4)/79.0 (20.9); p = 0.20; self-esteem: C 29.7 (4.7)/30.3 (4.7) vs I 29.2 (5.0)/29.5 (4.4); p = 0.84
C: control group; I: intervention group, RCT: randomized controlled trial, SD: standard deviation. 5
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vignettes of parent–child interactions, group discussion, role-play, rehearsal of parenting techniques, and home practice. Mental health outcomes In the paper by Friedman et al. (2009), the outcomes related to mental health were measured using a General Self-efficacy Questionnaire, a Health Self-efficacy Questionnaire, the Three Multidimensional Health Locus of Control subscales, and the Mental Health Component of the Short Form 36 (SF-36). After a follow-up of 22 months, the authors did not find any statistically significant difference between the control and the intervention group. Wissow et al (2008) evaluated the mental health of parents using the General Health Questionnaire (GHQ). After 6 months of follow-up, they found that parents who were treated by trained professionals improved their mental health status (a reduction of 1.7 points on the GHQ questionnaire; 95% CI − 3.2. to −0.11; p = 0.035). However the effect size of the intervention calculated using Cohen's D was small (0.31). Patterson et al (2002) also evaluated the mental health outcomes with the GHQ, although they included other measures such as the Parenting Stress Index, and the Self-esteem Scale. After 6 months of follow-up, the differences in the outcomes were not statistically significant. Discussion Our review indicates that MHP activities conducted by primary health providers have been focused on older people with disabilities and parenting. This is consistent with previous reviews conducted in other settings (Mcdaid and Park, 2011). However, great caution must be exercised in drawing any strong conclusion due to the dearth of data identified (only 3 studies) and their low-moderate quality. Consequently, the most important result of this systematic review is that we do not have enough evidence to recommend—or not—the implementation of MHP activities in the primary health care setting. In spite of this, in 1 out of the 3 studies a small effect was detected (Wissow et al., 2008). We acknowledge that the lack of studies can be a result of the criteria we used. The studies where the primary care professionals were only recruiting or referring patients to other services (mental health services, other community services) were excluded. In that sense, we may have excluded effective mental health interventions delivered by other professionals and in other sectors. However, our main aim was to focus on the active role of primary health care providers in the promotion of mental health. This review was done to inform the design of a complex intervention to be used mainly by primary health physicians and nurses, so we want to be realistic. If we have added interventions delivered by other professionals with different skills, this review will not have been useful for our purpose. On the other hand, it could be possible that primary health professionals are doing MHP activities, without evaluating and/or publishing them. The integration of MHP activities into primary care should be seen as a part of a global strategy to promote the mental health and wellbeing of the population. As well as there are school-based and workplace-based mental health promotion initiatives, primary health care centers also can play a crucial role in the promotion of mental health. In our opinion, frontline clinicians (primary care doctors, nurses, social workers) are in a key position to promote the mental health of the population (wide access to large samples), but at the same time, these professionals usually have to work under time pressure, being not able to adequately identify, assess, and treat the mental health problems of their patients. Consequently, as it is stated by the WHO (2008) it is important to put in place strategies to ensure that primary health care workers are able to apply psychosocial and behavioral skills in their daily work in order to improve overall (i.e. including mental) health outcomes. More research is needed to clearly understand the benefits of promoting
mental health in this setting and how to incorporate the promotion of mental health activities, taking into account the competing demands of clinical practice. In this line, a recent paper on how to integrate MHP into health services delivery suggested that the main problem is that health professionals lack the knowledge, skills, and selfconfidence to effectively promote mental health and wellbeing, so that there is the need to support and train them if MHP is to be incorporated into the health system (Rauscher et al., 2013). In some sense, the paper by Wissow et al. (2008), the only one with some positive results, suggests that professionals with better training in mental health issues could impact the mental health-related outcomes of their patients. Also, there is the need of a real community-based collaboration, meaning that the primary care professionals are playing an active role, sharing common goals with other stakeholders and working together (Carmola Hauf and Bond, 2002; Woltmann et al., 2012). Perceived lack of skills, inexistent collaboration between professionals, and scarce (or absent) evidence are important barriers to the implementation of overall health promotion activities (Rubio-Valera et al., 2014). However, some activities are showing promising results and could be easily translated to primary health care settings. These are related to educational mental health literacy workshops, such as the Mental Health First Aid Kit (Jorm et al., 2005, 2007, 2010a,b, which aims to raise the general level of knowledge about mental health and how to improve it; or interventions to promote the mental wellbeing of the elderly, regardless of their health status, focusing on life skills and the promotion of social networks (Forsman et al., 2011). Maybe the more realistic strategy is to enrich the health promotion activities focused on physical activity, healthy diet, or reduction of alcohol intake or smoking with activities targeting self-esteem and self-efficacy (Kelly et al., 1991); another options could be to promote mental health by social prescription activities (see the review by March in this supplement). Limitations and strengths This systematic review has a number of limitations, which have an impact on its validity. First, MHP outcomes are hard to define. We included in our search strategy terms such as “mental health”, “positive psychology”, “empowerment”, “mental health”, “mental well being”, “psychological well being”,“mental quality of life”, and “wellness”. It is possible that we missed some papers that defined other outcomes. However, it would be rare for a paper reporting on a study that aimed to promote mental health to not include mental health as a key word. Second, we have restricted our review to English or Spanish materials. Lastly, the studies selected were conducted in USA and in the UK. Primary care in other countries may be quite different, requiring a specific approach taking into account cultural aspects. In spite of the above limitations, this is thought to be the first systematic review of the effectiveness of interventions delivered by primary health care providers that actively aimed to promote mental health. The process was carried out in duplicate and strictly followed the PRISMA guidelines. As the relatively new field of MHP is evolving, we adopted a sensitive strategy, with no restrictive filters. This strategy led us to review a huge amount of papers that were manually excluded. However, we are confident that we have included all the information relevant to answering our research question. Conclusion In conclusion, in spite of the idea that MHP may be integrated into primary health care, there is a lack of implementation and/or evaluation of these initiatives. As we only found 3 papers dealing with this issue, more efforts are needed in order to understand why this is happening. It is also important to identify the benefits and weaknesses of primary care-based MHP interventions. Research carried out in other settings has suggested that MHP is effective in empowering people to cope
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
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with stressors, thereby improving their resilience (Mcdaid and Park, 2011). The challenge is how to integrate MHP into the primary health care keeping in mind the complexity and barriers of this setting. Conflict of interest statement No authors have any competing interests.
Funding The project has received funding from a Network for Prevention and Health Promotion in Primary Care (redIAPP, RD12/0005) grant and a research project grant (PI12/01914) from the Instituto de Salud Carlos III (Institute of Health Carlos III) of the Ministry of Economy and Competitiveness (Spain), co-financed with the European Union ERDF funds. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ypmed.2014.11.019. References Almeida, D.M., Wethington, E., Kessler, R.C., 2002. The daily inventory of stressful events — an interview-based approach for measuring daily stressors. Assessment 9, 41–55. Barry, M.M., Clarke, A.M., Jenkins, R., Patel, V., 2013. A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health 13. Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., et al., 2011. The Global Economic Burden of Non-communicable Diseases. World Health Organization, Geneve. Camh, 2010. Best Practice Guidelines for Mental Health Promotion Programs: Older Adults 55+. (Retrieved from: https://knowledgex.camh.net/policy_health/ mhpromotion/mhp_older_adults/Documents/mhp_55plus.pdf). Carmola Hauf, A.M., Bond, L.A., 2002. Community-based collaboration in prevention and mental health promotion: benefits from building the resources of partnership. Int. J. Ment. Health Promot. 4, 41–54. Chapin, R.K., Sergeant, J.F., Landry, S., et al., 2013. Reclaiming joy: pilot evaluation of a mental health peer support program for older adults who receive Medicaid. Gerontologist 53, 345–352. Czabala, C., Charzynska, K., Mroziak, B., 2011. Psychosocial interventions in workplace mental health promotion: an overview. Health Promot. Int. 26, I70–I84. Evans, S.W., Mullett, E., Weist, M.D., Franz, K., 2005. Feasibility of the MindMatters school mental health promotion program in American schools. J. Youth Adolesc. 34, 51–58. Forsman, A.K., Nordmyr, J., Wahlbeck, K., 2011. Psychosocial interventions for the promotion of mental health and the prevention of depression among older adults. Health Promot. Int. 26, I85–I107. Franze, M., 2004. Mind matters projects for mental health promotion in schools. Gesundheitswesen 66, 626–627. Friedman, B., Wamsley, B.R., Liebel, D.V., Saad, Z.B., Eggert, G.M., 2009. Patient satisfaction, empowerment, and health and disability status effects of a disease managementhealth promotion nurse intervention among medicare beneficiaries with disabilities. Gerontologist 49, 778–792. Gerrity, M.S., Williams, J.W., Dobscha, S.K., et al., 2004. Improving depression care: systematic review of multifaceted interventions in primary care settings. J. Gen. Intern. Med. 19, 166-66. Gilbody, S., Whitty, P., Grimshaw, J., Thomas, R., 2003. Educational and organizational interventions to improve the management of depression in primary care — a systematic review. JAMA 289, 3145–3151. Gunn, J., Diggens, J., Hegarty, K., Blashki, G., 2006. A systematic review of complex system interventions designed to increase recovery from depression in primary care. BMC Health Serv. Res. 6. Ichida, Y., Hirai, H., Kondo, K., Kawachi, I., Takeda, T., Endo, H., 2013. Does social participation improve self-rated health in the older population? A quasi-experimental intervention study. Soc. Sci. Med. 94, 83–90. Jadad, A.R., Moore, R.A., Carroll, D., et al., 1996. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control. Clin. Trials 17, 1–12. Jorm, A.F., Blewitt, K.A., Griffiths, K.M., Kitchener, B.A., Parslow, R.A., 2005. Mental health first aid responses of the public: results from an Australian national survey. BMC Psych. 5. Jorm, A.F., Kitchener, B.A., Kanowski, L.G., Kelly, C.M., 2007. Mental health first aid training for members of the public. Int. J. Clin. Health Psychol. 7, 141–151. Jorm, A.F., Kitchener, B.A., Fischer, J.A., Cvetkovski, S., 2010a. Mental health first aid training by e-learning: a randomized controlled trial. Aust. NZ J. Psychiatry 44, 1072–1081. Jorm, A.F., Kitchener, B.A., Sawyer, M.G., Scales, H., Cvetkovski, S., 2010b. Mental health first aid training for high school teachers: a cluster randomized trial. BMC Psychiatry 10. Joubert, N., Taylor, L., Williams, I., 1996. Mental Health Promotion: The Time Is Now. Mental Health Promotion Unit, Health Canada, Ottawa.
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Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Review
Is there a case for mental health promotion in the primary care setting? A systematic review Ana Fernandez a,b,c,j,⁎,1, Patricia Moreno-Peral c,d, Edurne Zabaleta-del-Olmo c,e,f, Juan Angel Bellon c,d,g, Jose Manuel Aranda-Regules c,d,h, Juan Vicente Luciano b,c,i, Antoni Serrano-Blanco b,c, Maria Rubio-Valera b,c,i,1 a
Centre for Disability Research and Policy/Brain and Mind Research Institute, Faculty of Health Sciences, University of Sydney, Australia Research and Development Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain Network for Prevention and Health Promotion in Primary Care (RedIAPP, ISCIII), Spain d Instituto de Investigación Biomédica de Málaga (IBIMA), Unidad de Investigación del Distrito de Atención Primaria de Málaga, Spain e Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Barcelona, Spain f Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain g Centro de Salud El Palo, Distrito de Atención Primaria Málaga-Guadalohorce, Departamento de Medicina Preventiva, Universidad de Málaga, Spain h Centro de Salud San Andrés Torcal, Distrito Sanitario Málaga-Guadalhorce, Servicio Andaluz de Salud, Málaga, Spain i Open University of Catalonia, Barcelona, Spain j Department of Pharmacology and Therapeutic Chemistry, School of Pharmacy, Universitat de Barcelona, Spain b c
a r t i c l e
i n f o
a b s t r a c t
Available online xxxx
Objectives. To evaluate the effectiveness of mental health promotion (MHP) interventions by primary health care professionals in the adult population. Methods. Systematic review of literature in English and Spanish for randomized controlled trials (RCTs) and observational studies evaluating the impact of interventions carried out by primary care professionals explicitly to promote and improve the overall mental health of adult patients. PubMed, PsycINFO, and Web of Science were independently searched by two investigators to identify all MHP articles from inception to October 2013 (no restrictions). Results. We retrieved 4262 records and excluded 4230 by a review of title and abstract. Of 32 full-text articles assessed, 3 RCTs were selected (2 in USA, 1 in UK); two focused on the mental health of parents whose children have behavioral problems, the other on older people with disabilities. One study reported a MHP intervention that improved participants' mental health at 6-month follow-up. All studies had low-moderate quality (2 of 5 points) on the Jadad Scale. Conclusion. There is a lack of implementation and/or evaluation of mental health promotion activities conducted by primary care professionals. More research is needed to clearly understand the benefits of promoting mental health in this setting. © 2014 Published by Elsevier Inc.
Keywords: Health promotion Mental health Primary health care Systematic review
Contents Introduction . . . . . . . . . . Method . . . . . . . . . . . . Literature search . . . . . . Study selection . . . . . . Eligibility criteria . . . . . . Population/promotion Intervention . . . . Comparison . . . . . Outcomes . . . . . .
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⁎ Corresponding author at: Centre for Disability Research and Policy — Brain and Mind Research Institute, Faculty of Health Sciences T432a Cumberland Campus, The University of Sydney, 75 East Street, Lidcombe, NSW 2141, Australia. Fax: +61 2 9351 9566. E-mail address: [email protected] (A. Fernandez). 1 Ana Fernandez and Maria Rubio-Valera contributed equally to this work.
http://dx.doi.org/10.1016/j.ypmed.2014.11.019 0091-7435/© 2014 Published by Elsevier Inc.
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
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Risk of bias in individual studies . . . Data extraction . . . . . . . . . . . Synthesis of results . . . . . . . . . Results . . . . . . . . . . . . . . . . . Literature search and study selection . Characteristics of the included studies Risk of bias . . . . . . . . . Description of interventions . . Mental health outcomes . . . Discussion . . . . . . . . . . . . . . . Limitations and strengths . . . . . . Conclusion . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . Funding . . . . . . . . . . . . . . . . Appendix A. Supplementary data . . . . References . . . . . . . . . . . . . . .
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Introduction Mental Health has been defined as ‘a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ (WHO, 2010). Therefore, the promotion of good mental health is critical not only for the person, but also for society. People with poor mental health have lower life expectancy. This difference is explained both by suicide rates and by the higher prevalence of chronic medical conditions (e.g., cardiovascular disorders, cancer) in this population (Lawrence et al., 2013). In addition, mental disorders are associated with high disability and related costs for society, a substantial proportion of which are due to absences and loss of productivity (Bloom et al., 2011), as well as to earlier retirement of withdrawal from the workforce (Mcdaid and Park, 2011). With the increasing recognition of the burden associated with mental illnesses (Whiteford et al., 2013), there has been a rise in research on mental health promotion (MHP). In 1996, MHP was defined as ‘the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health. Mental health promotion uses strategies that foster supportive environments and individual resilience, while showing respect for culture, equity, social justice, interconnections, and personal dignity’ (Joubert et al., 1996). Five years later, the World Health Organization (WHO, 2001) described MHP as “(…) an umbrella term that covers a variety of strategies all aimed at having a positive effect on mental health. The encouragement of individual resources and skills and improvement in the socioeconomic environment are among them”. Both definitions suggest that MHP requires initiatives both at macro level (e.g., policies leading with inequity and promoting social justice) and micro level (e.g., individual interventions). Although MHP and health promotion share the values presented in the Ottawa Charter (1986), there are two major differences. First, MHP directly aims to increase resilience and empower people, by increasing their ability to cope with significant adversity or stressful life events (CAMH, 2010). Second, MHP targets the cognitive, social, and emotional skills (e.g., problem solving, social skills, and social support), while health promotion is focused on lifestyle factors (e.g., promotion of physical activity and healthy eating and reduction of smoking and drinking behaviors). It is important to highlight that these approaches are complementary: healthy lifestyles increase mental wellbeing (Penedo and Dahn, 2005), and by improving emotional wellness we also improve physical health (Wiest et al., 2011). MHP also differs from primary prevention of mental disorders. Primary prevention focuses on reducing or eliminating the risk factors for a specific pathology. In contrast, MHP targets a broad variety of problems and focuses on the positive factors (Stachtchenko and Jenicek, 1990). However, the two approaches overlap and are interrelated,
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making it difficult to separate them in day-to-day practice. It is known that multiple risk and protective factors are involved in the onset of mental disorders; therefore, most initiatives designed to prevent specific mental disorders also include strategies to improve the protective factors. The main difference, then, is in the final aim: MHP aims to enhance overall wellbeing, not to “fight” against a specific disease (Min et al., 2013; Saxena and Maulik, 2002; Stachtchenko and Jenicek, 1990; WHO, 2004). Finally, MHP differs from therapeutic interventions because it targets the general healthy population, while treatment focuses on people who are already ill. Although people with mental disorders may be able to benefit from MHP initiatives, this population is not the main target of these strategies (Min et al., 2013; Saxena and Maulik, 2002; Stachtchenko and Jenicek, 1990; WHO, 2004). In summary, MHP has a primary preventive component (i.e., the main target is the healthy people), but focuses on positive aspects of mental wellbeing. It is valued to separate prevention and promotion strategies in the field of mental health, because it facilitates giving adequate attention to both, and it is easier for decision-makers to evaluate the results of the programs (Saxena and Maulik, 2002). The effectiveness of MHP interventions has been well documented in school settings (Barry et al., 2013; Evans et al., 2005; Franze, 2004; Michaelsen-Gartner and Witteriede, 2009; Mishara and Ystgaard, 2006; Roberts et al., 2003; Weare and Nind, 2011), at the workplace (Czabala et al., 2011; Lerner et al., 2013; Mattke and Van Busum, 2013; Patel et al., 2013; Sun et al., 2013; Torp et al., 2013; Tsutsumi et al., 2009), and in community centers serving older adults (Chapin et al., 2013; Forsman et al., 2011; Ichida et al., 2013). This is in line with the results of a recent systematic review (Mcdaid and Park, 2011) and a report presenting different economic models for mental health promotion and prevention (Knapp et al., 2011). Both documents concluded that there is a case for some interventions to promote mental health and wellbeing in some very specific contexts and settings. However, just one of the contexts analyzed in these documents included primary care centers, and it was for alcohol misuse. In theory, primary health care centers are, well positioned within the community to perform the MHP activities. Primary care is in the “front lines” of health care delivery and serves as the primary point of contact for most individuals in most health systems. This venue is therefore among the most accessible in health care and likeliest to reach a larger swath of the population. Equipping these professionals with mental health skills promotes a more holistic and integrated approach and ensures not only improved detection and treatment, but also prevention of mental disorders and promotion of mental health and wellbeing (WHO, 2008). The role of primary health care professionals dealing with mental disorders have been highlighted in different reviews, concluding that primary health care providers can treat common mental disorders, specially depression (Gerrity et al., 2004; Gilbody et al., 2003; Gunn et al., 2006; Woltmann et al., 2012); however, as we
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
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have already stated, little is known about MHP delivered at primary care centers by primary health professionals. This systematic review is part of a series of reviews aiming to establish the evidence base for the promotion of different healthy behaviors, the prevention of cardiovascular diseases, and the prevention of depression and anxiety at the primary health care level. All this information was combined to design a complex intervention for dealing with multiple risk factors in order to prevent multimorbidity, which is currently a hot topic in primary care (Smith et al., 2012). The inclusion of interventions to promote overall mental health (and not just preventing specific conditions) fills a gap and provides a more holistic view. To the best of our knowledge, this is the first review to evaluate the effectiveness of MHP interventions delivered by primary health care professionals to their adult patients. Method We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (Moher et al., 2009). Literature search We performed a systematic review of the published literature for randomized controlled trials (RCTs) and observational studies evaluating the impact of interventions made by primary health care professionals (general practitioner, nurses, and social workers) explicitly aiming to promote and improve the overall mental health of adult patients. The PubMed, PsycINFO, and Web of Science datasets were independently searched by two investigators (AF and MRV) to identify all articles involving MHPs. We completed literature searches from database inception to October 2013, with no restrictions, using free text and controlled vocabulary terms. The search strategies used can be consulted in Supplemental file 1. Titles and/or abstracts of all citations were obtained for study selection. Reference lists of retrieved articles were checked for additional studies not identified in the original database search. Expert informants from the Primary Care Prevention and Health Promotion Research Network REDIAPP (www. rediapp.org) were consulted to retrieve gray literature (such as unpublished reports and conference abstracts). One of the reviewers (AF) also searched the Cochrane Library and the “International Journal of Mental Health Promotion”, a key journal not indexed in the databases used. Study selection Studies were screened for inclusion in two phases and the entire process was carried out in duplicate (AF and MRV). In phase 1, records were selected by reviewing the title and/or the published abstract. In phase 2, the full-text article was reviewed. In case of any disagreement, researchers discussed the problems, trying to reach a consensus. When a consensus was not reached, a third co-author read the paper. Eligibility criteria Population/promotion As discussed in the Introduction, the MHP concept has the problem of not being very specific. If we include all the strategies that have a positive effect on mental health, we would have to include all activities ranging from the prevention of mental disorders to their treatment. This review focused only on those MHP interventions that targeted mainly healthy people. The reviews focused on the effectiveness of MHP interventions usually exclude those delivered to people diagnosed with mental disorders (Mcdaid and Park, 2011). Therefore, we included only those interventions conducted with adult (N17 years old) primary care patients with no such diagnosis at the time of the study. Intervention We only included interventions whose primary objective was to improve participants' mental health by increasing their ability to cope with daily stressors. Daily stressors are defined as routine challenges of day-to-day living, such as the everyday concerns of work, caring for other people, and commuting between work and home. They may also refer to more unexpected small occurrences—such as arguments with children, and unexpected work
3
deadlines—that disrupt daily life (Almeida et al., 2002). Activities such as problem-solving techniques, cognitive restructuring, relaxation, and interventions to increase self-esteem, resilience, and/ or self-efficacy were included. In consequence, we excluded those health promotion interventions (such as promotion of physical activity or healthy diet) that included mental health outcomes as a secondary aim, but were not focused on life skills. We were interested in interventions delivered by the key professionals that are common across different primary health care systems (general practitioners or family physicians, primary care nurses, and social workers). This definition excluded all studies in which the role of the primary health care professional was limited to the referral of participants to specialized or social services without any additional involvement. The impact of social prescribing or community activities on overall wellbeing can be seen elsewhere in the supplement. Comparison We included those studies that compared MHP interventions with the usual care. Outcomes Any global measure of mental wellbeing, mental health, wellness or mental health related quality of life was included. Studies using condition-specific measures (such as depression or anxiety) are reviewed elsewhere in the supplement. To focus on the most up-to-date information and ensure that the researchers had access to a formal definition of MHP (Joubert et al., 1996), we excluded those papers written before 1997. Only papers written in English or Spanish were considered. Risk of bias in individual studies The quality of the selected studies was assessed independently by AF and MRV using the Jadad (Jadad et al., 1996) scale, which considers 3 features of a study: randomization, double-blinding, and flow of patients. Scores range from 0 to 5, with the higher scores indicating higher quality. If we had included any observational study, we would have used the list of quality criteria suitable for evaluating this type of studies (Mallen et al., 2006). However, none of the papers included was an observational study. Data extraction Two reviewers (AF and MRV) independently extracted key features of the characteristics, methods, and outcomes of articles that met the inclusion criteria. The key features included study design, period of study, setting, sample size, primary care professionals involved, intervention components, the main outcome measures reported by the authors, results, and conclusions. In the case of disagreement, researchers reviewed the data looking for a consensus. A third reviewer (PMP) also checked the data. Synthesis of results Due to the small number of studies selected, their clinical heterogeneity, and their low quality (see Results), we decided not to combine data.
Results Literature search and study selection The electronic search strategy identified 5633 records, while 29 trials and 2 systematic reviews were retrieved via the Cochrane Library. Using the search engine at the “International Journal of Mental Health Promotion”, AF also retrieved 166 records that included anywhere the words “primary care”. After removing all records previous to 1997 and those that were duplicated, 4262 were reviewed. A total of 4230 were excluded by reviewing title and abstract. Of the 32 full-text articles assessed for eligibility, 3 were selected by both researchers, 24 were excluded by both, and both authors had doubts about 5 articles. Both researchers, in collaboration with other co-authors, reviewed and discussed those papers, finally agreeing to exclude them (Fig. 1).
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
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Fig. 1. Flow diagram of the study inclusion process.
Characteristics of the included studies We identified 3 studies for inclusion in this systematic review (Friedman et al., 2009; Patterson et al., 2002; Wissow et al., 2008). Table 1 summarizes the main characteristics of these studies. Two of the studies were conducted in USA (Friedman et al., 2009; Wissow et al., 2008) and one in UK (Patterson et al., 2002). The studies were conducted between 2002 and 2009. Regarding the type of study sample, that of Friedman et al. (2009) was conducted in elderly Medicare beneficiaries with disabilities, while the other 2 studies focused on the mental health of parents whose children have mental or behavioral problems (Patterson et al., 2002; Wissow et al., 2008). The primary care professionals who delivered the interventions were nurses (Friedman et al., 2009; Patterson et al., 2002; Wissow et al., 2008) and family physicians (Wissow et al., 2008). All 3 studies were RCTs and the comparator was usual care. Two of them stated that they analyzed the data according to intention-totreat (Patterson et al., 2002; Wissow et al., 2008) although they did not explain how they handled dropouts and missing data.
Risk of bias Methodological quality scored 2 out of 5 (low-moderate) in all 3 papers. Just one paper generated discrepancies between the 2 researchers (AF and MRV) that were discussed until reaching a consensus. The main problems of the paper by Friedman et al. (2009) were related to an inadequate explanation of randomization, and the fact of not being blinded. However, the blinding of participants is very difficult in this
type of interventions. The problems of the paper by Patterson et al. (2002) were also related with blinding and a lack of complete explanation of withdrawals. Finally, the paper by Wissow et al. (2008) was limited by an inadequate explanation of the randomization process and of dropouts and withdrawals. By contrast, in this study both assessors and patients were blinded to the intervention. Description of interventions The intervention tested in the paper by Friedman et al. (2009) was based on the PRECEDE health education planning model. The nurses made home visits an average of once a month during 22 months (mean number of visits, 19; standard deviation (SD) 1). During those visits they reviewed medications but also tried to empower the patients by educating them in how to better manage their chronic diseases. The intervention tested by Wissow et al. (2008) was a training program in mental health care interventions for primary care practitioners (from different types of community centers). The rationale behind this intervention was that once professionals were trained, they could have the skills to educate their patients on how to deal with their problems. The provider training was based on active learning and locally relevant content. It consisted of 3 sessions. The skills trained were related to solution-focused cognitive therapy, motivation, and family engagement. On the other hand, the paper by Patterson et al. (2002) evaluated the impact of the Webster-Stratton Parents and Children Series. The intervention consists of 10 weekly sessions, each about 2 h long and led by a home health visitor and either a second home health visitor or a nurse. The activities carried out during the sessions include video
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
Study
Friedman USA et al. (2009)
Wissow et al. (2008)
% of Women (C/I)
Mean age (C/I)
Design Follow-up (in months)
Description of the intervention
766 (384/382)
68.8 (69.5/68.1)
77.3 (77.5/77.2)
RCT
11 nurses After an initial home assessment visit, the nurse made home visits an average of once a month. In these visits, she reviewed the patient's medications and used the theoretical models of the PRECEDE health education planning model to help address disease prevention, health promotion, chronic disease self-care and self-management, and health behaviour change and maintenance.
418 families (170/248)
90.7 (89/92)
37.6 (SD9.5)/36.8 (SD7.6)
Cluster RCT
6
116 parents (56/60)
Not provided
Not provided
Block RCT
6
Country Sample (C/I)
USA
Patterson UK et al. (2002)
22
The training contained communication skills that built on providers' existing knowledge of child behaviour and development. Skills were drawn from patient-centered care, family therapy, solution-focused cognitive therapy, motivational enhancement, and family engagement. Training was delivered in 3 cycles, spaced 3 weeks apart. Each cycle began with a 60-min, small-group discussion, held on-site during work hours and led by a child psychiatrist. The discussion used a computerized slide set containing background material, written and video examples of skills, and programmed pauses for interaction. The intervention comprised sessions lasting about 2 h each, once a week for 10 weeks. The activities included video vignettes of parent–child interactions, group discussion, role-play, rehearsal of parenting techniques, and home practice. The techniques covered included play and positive interaction with the child, clear commands, limit setting, ignoring undesirable behaviour, praising and rewarding desirable behaviour, and following through on discipline.
Professionals involved in the Intervention
48 physicians, 9 nurse practitioners, and 1 physician's assistant, from different sites (urban and rural community base)
Main mental health measure
Differences
General self-efficacy; health self-efficacy; internal health locus of control scale; powerful others health locus of control scale; chance health locus of control scale; mental health component summary (SF-36); activities of daily living: instrumental activities of daily living
Adjusted results at 20 months (β; SE; p value) general self-efficacy (−0.01;0.27; 0.96); health self-efficacy (−0.25;0.22; 0.26); internal health locus of control scale (−0.37;0.,35,0.29); powerful others health locus of control scale (−0.26;0.38;0.50); chance health locus of control scale (−0.33;0.42;0.43) mental health component summary (SF-36) (0.81;0.85,0.34); activities of daily living-dependence (-0.25;0.12,0.04*); instrumental activities of daily living-dependence (0.16;0.12,0.18) Seeing a trained provider was associated with a significantly greater decrease (on average −1.7 GHQ points; 95% CI −3.2 to −0.11; p = 0.035: effect size 0.31)
General Health Questionnaire (GHQ): the Parenting Stress Index (PSI) and the Self Esteem Scale
General Health Questionnaire Each group was run by at least one health visitor with (GHQ): the Parenting Stress Index either a second health visitor (PSI) and the Self Esteem Scale or a nursery nurse as co-leader in 3 general practices in Oxford
A. Fernandez et al. / Preventive Medicine xxx (2014) xxx–xxx
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
Table 1 Summary of the papers included in this review.
Means (SD) at baseline and 6 months follow-up by group (C/I) and p value: GHQ: C 4.3 (4.9)/3.0 (4.6) vs I 5.1 (4.9)/2.7 (4.2); p = 0.24; PSI: C 86.5 (18.4)/83.4 (17.0) vs I 85.0 (20.4)/79.0 (20.9); p = 0.20; self-esteem: C 29.7 (4.7)/30.3 (4.7) vs I 29.2 (5.0)/29.5 (4.4); p = 0.84
C: control group; I: intervention group, RCT: randomized controlled trial, SD: standard deviation. 5
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vignettes of parent–child interactions, group discussion, role-play, rehearsal of parenting techniques, and home practice. Mental health outcomes In the paper by Friedman et al. (2009), the outcomes related to mental health were measured using a General Self-efficacy Questionnaire, a Health Self-efficacy Questionnaire, the Three Multidimensional Health Locus of Control subscales, and the Mental Health Component of the Short Form 36 (SF-36). After a follow-up of 22 months, the authors did not find any statistically significant difference between the control and the intervention group. Wissow et al (2008) evaluated the mental health of parents using the General Health Questionnaire (GHQ). After 6 months of follow-up, they found that parents who were treated by trained professionals improved their mental health status (a reduction of 1.7 points on the GHQ questionnaire; 95% CI − 3.2. to −0.11; p = 0.035). However the effect size of the intervention calculated using Cohen's D was small (0.31). Patterson et al (2002) also evaluated the mental health outcomes with the GHQ, although they included other measures such as the Parenting Stress Index, and the Self-esteem Scale. After 6 months of follow-up, the differences in the outcomes were not statistically significant. Discussion Our review indicates that MHP activities conducted by primary health providers have been focused on older people with disabilities and parenting. This is consistent with previous reviews conducted in other settings (Mcdaid and Park, 2011). However, great caution must be exercised in drawing any strong conclusion due to the dearth of data identified (only 3 studies) and their low-moderate quality. Consequently, the most important result of this systematic review is that we do not have enough evidence to recommend—or not—the implementation of MHP activities in the primary health care setting. In spite of this, in 1 out of the 3 studies a small effect was detected (Wissow et al., 2008). We acknowledge that the lack of studies can be a result of the criteria we used. The studies where the primary care professionals were only recruiting or referring patients to other services (mental health services, other community services) were excluded. In that sense, we may have excluded effective mental health interventions delivered by other professionals and in other sectors. However, our main aim was to focus on the active role of primary health care providers in the promotion of mental health. This review was done to inform the design of a complex intervention to be used mainly by primary health physicians and nurses, so we want to be realistic. If we have added interventions delivered by other professionals with different skills, this review will not have been useful for our purpose. On the other hand, it could be possible that primary health professionals are doing MHP activities, without evaluating and/or publishing them. The integration of MHP activities into primary care should be seen as a part of a global strategy to promote the mental health and wellbeing of the population. As well as there are school-based and workplace-based mental health promotion initiatives, primary health care centers also can play a crucial role in the promotion of mental health. In our opinion, frontline clinicians (primary care doctors, nurses, social workers) are in a key position to promote the mental health of the population (wide access to large samples), but at the same time, these professionals usually have to work under time pressure, being not able to adequately identify, assess, and treat the mental health problems of their patients. Consequently, as it is stated by the WHO (2008) it is important to put in place strategies to ensure that primary health care workers are able to apply psychosocial and behavioral skills in their daily work in order to improve overall (i.e. including mental) health outcomes. More research is needed to clearly understand the benefits of promoting
mental health in this setting and how to incorporate the promotion of mental health activities, taking into account the competing demands of clinical practice. In this line, a recent paper on how to integrate MHP into health services delivery suggested that the main problem is that health professionals lack the knowledge, skills, and selfconfidence to effectively promote mental health and wellbeing, so that there is the need to support and train them if MHP is to be incorporated into the health system (Rauscher et al., 2013). In some sense, the paper by Wissow et al. (2008), the only one with some positive results, suggests that professionals with better training in mental health issues could impact the mental health-related outcomes of their patients. Also, there is the need of a real community-based collaboration, meaning that the primary care professionals are playing an active role, sharing common goals with other stakeholders and working together (Carmola Hauf and Bond, 2002; Woltmann et al., 2012). Perceived lack of skills, inexistent collaboration between professionals, and scarce (or absent) evidence are important barriers to the implementation of overall health promotion activities (Rubio-Valera et al., 2014). However, some activities are showing promising results and could be easily translated to primary health care settings. These are related to educational mental health literacy workshops, such as the Mental Health First Aid Kit (Jorm et al., 2005, 2007, 2010a,b, which aims to raise the general level of knowledge about mental health and how to improve it; or interventions to promote the mental wellbeing of the elderly, regardless of their health status, focusing on life skills and the promotion of social networks (Forsman et al., 2011). Maybe the more realistic strategy is to enrich the health promotion activities focused on physical activity, healthy diet, or reduction of alcohol intake or smoking with activities targeting self-esteem and self-efficacy (Kelly et al., 1991); another options could be to promote mental health by social prescription activities (see the review by March in this supplement). Limitations and strengths This systematic review has a number of limitations, which have an impact on its validity. First, MHP outcomes are hard to define. We included in our search strategy terms such as “mental health”, “positive psychology”, “empowerment”, “mental health”, “mental well being”, “psychological well being”,“mental quality of life”, and “wellness”. It is possible that we missed some papers that defined other outcomes. However, it would be rare for a paper reporting on a study that aimed to promote mental health to not include mental health as a key word. Second, we have restricted our review to English or Spanish materials. Lastly, the studies selected were conducted in USA and in the UK. Primary care in other countries may be quite different, requiring a specific approach taking into account cultural aspects. In spite of the above limitations, this is thought to be the first systematic review of the effectiveness of interventions delivered by primary health care providers that actively aimed to promote mental health. The process was carried out in duplicate and strictly followed the PRISMA guidelines. As the relatively new field of MHP is evolving, we adopted a sensitive strategy, with no restrictive filters. This strategy led us to review a huge amount of papers that were manually excluded. However, we are confident that we have included all the information relevant to answering our research question. Conclusion In conclusion, in spite of the idea that MHP may be integrated into primary health care, there is a lack of implementation and/or evaluation of these initiatives. As we only found 3 papers dealing with this issue, more efforts are needed in order to understand why this is happening. It is also important to identify the benefits and weaknesses of primary care-based MHP interventions. Research carried out in other settings has suggested that MHP is effective in empowering people to cope
Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
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with stressors, thereby improving their resilience (Mcdaid and Park, 2011). The challenge is how to integrate MHP into the primary health care keeping in mind the complexity and barriers of this setting. Conflict of interest statement No authors have any competing interests.
Funding The project has received funding from a Network for Prevention and Health Promotion in Primary Care (redIAPP, RD12/0005) grant and a research project grant (PI12/01914) from the Instituto de Salud Carlos III (Institute of Health Carlos III) of the Ministry of Economy and Competitiveness (Spain), co-financed with the European Union ERDF funds. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ypmed.2014.11.019. References Almeida, D.M., Wethington, E., Kessler, R.C., 2002. The daily inventory of stressful events — an interview-based approach for measuring daily stressors. Assessment 9, 41–55. Barry, M.M., Clarke, A.M., Jenkins, R., Patel, V., 2013. A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health 13. Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., et al., 2011. The Global Economic Burden of Non-communicable Diseases. World Health Organization, Geneve. Camh, 2010. Best Practice Guidelines for Mental Health Promotion Programs: Older Adults 55+. (Retrieved from: https://knowledgex.camh.net/policy_health/ mhpromotion/mhp_older_adults/Documents/mhp_55plus.pdf). Carmola Hauf, A.M., Bond, L.A., 2002. Community-based collaboration in prevention and mental health promotion: benefits from building the resources of partnership. Int. J. Ment. Health Promot. 4, 41–54. Chapin, R.K., Sergeant, J.F., Landry, S., et al., 2013. Reclaiming joy: pilot evaluation of a mental health peer support program for older adults who receive Medicaid. Gerontologist 53, 345–352. Czabala, C., Charzynska, K., Mroziak, B., 2011. Psychosocial interventions in workplace mental health promotion: an overview. Health Promot. Int. 26, I70–I84. Evans, S.W., Mullett, E., Weist, M.D., Franz, K., 2005. Feasibility of the MindMatters school mental health promotion program in American schools. J. Youth Adolesc. 34, 51–58. Forsman, A.K., Nordmyr, J., Wahlbeck, K., 2011. Psychosocial interventions for the promotion of mental health and the prevention of depression among older adults. Health Promot. Int. 26, I85–I107. Franze, M., 2004. Mind matters projects for mental health promotion in schools. Gesundheitswesen 66, 626–627. Friedman, B., Wamsley, B.R., Liebel, D.V., Saad, Z.B., Eggert, G.M., 2009. Patient satisfaction, empowerment, and health and disability status effects of a disease managementhealth promotion nurse intervention among medicare beneficiaries with disabilities. Gerontologist 49, 778–792. Gerrity, M.S., Williams, J.W., Dobscha, S.K., et al., 2004. Improving depression care: systematic review of multifaceted interventions in primary care settings. J. Gen. Intern. Med. 19, 166-66. Gilbody, S., Whitty, P., Grimshaw, J., Thomas, R., 2003. Educational and organizational interventions to improve the management of depression in primary care — a systematic review. JAMA 289, 3145–3151. Gunn, J., Diggens, J., Hegarty, K., Blashki, G., 2006. A systematic review of complex system interventions designed to increase recovery from depression in primary care. BMC Health Serv. Res. 6. Ichida, Y., Hirai, H., Kondo, K., Kawachi, I., Takeda, T., Endo, H., 2013. Does social participation improve self-rated health in the older population? A quasi-experimental intervention study. Soc. Sci. Med. 94, 83–90. Jadad, A.R., Moore, R.A., Carroll, D., et al., 1996. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control. Clin. Trials 17, 1–12. Jorm, A.F., Blewitt, K.A., Griffiths, K.M., Kitchener, B.A., Parslow, R.A., 2005. Mental health first aid responses of the public: results from an Australian national survey. BMC Psych. 5. Jorm, A.F., Kitchener, B.A., Kanowski, L.G., Kelly, C.M., 2007. Mental health first aid training for members of the public. Int. J. Clin. Health Psychol. 7, 141–151. Jorm, A.F., Kitchener, B.A., Fischer, J.A., Cvetkovski, S., 2010a. Mental health first aid training by e-learning: a randomized controlled trial. Aust. NZ J. Psychiatry 44, 1072–1081. Jorm, A.F., Kitchener, B.A., Sawyer, M.G., Scales, H., Cvetkovski, S., 2010b. Mental health first aid training for high school teachers: a cluster randomized trial. BMC Psychiatry 10. Joubert, N., Taylor, L., Williams, I., 1996. Mental Health Promotion: The Time Is Now. Mental Health Promotion Unit, Health Canada, Ottawa.
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Please cite this article as: Fernandez, A., et al., Is there a case for mental health promotion in the primary care setting? A systematic review, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.11.019
