London Journal of Primary Care 2009;2:81–2
# 2009 Royal College of General Practitioners
London Landscape
WHO/WONCA report – Integrating Mental Health in Primary Care: A Global Perspective Trisha Greenhalgh Professor of Primary Health Care, London, UK
At the WONCA Asia Pacific annual conference in Melbourne, October 2008, WONCA President Chris Van Weel introduced what he called a ‘historic moment’. Four years in gestation and involving input from 12 countries in four continents, the joint WHO/WONCA report Integrating Mental Health in Primary Care - A Global Perspective was finally being launched. The 800 free copies were snapped up by delegates before the end of morning coffee (and disappointed latecomers were told they could download a pdf of the full report from www.who.int/mental_health/policy/en). Dr Michelle Funk, co-ordinator of Mental Health Services at WHO Geneva, introduced the report by reading the story of Juan, a 43-year-old man from a South American country who had developed schizophrenia in his mid-20s. Juan described how his life disintegrated soon after his diagnosis, with the loss of his job, a failed marriage, loss of contact with his children, and returning to live with his elderly mother who did her best under difficult circumstances. Juan received many years of hospital-based ‘treatment’, which typically took him away from his home and family and included numerous inpatient episodes which, despite ‘nice’ staff, he experienced as traumatic. He was sometimes made to receive treatment he didn’t want or understand, and went hungry because the food in hospital was inadequate. When discharged, Juan often missed his outpatient appointments (and hence his injections) because he could not afford the bus fare to the city. But the story had a relatively happy ending: Juan now receives his regular medication in a community based clinic three blocks from his home, from a nurse he knows and likes. He feels understood and supported, and looks forward to his fortnightly visits to the clinic. He’s currently well, but if he develops problems, he will be able to see a psychiatric nurse at a community outreach clinic without the need for a trip to hospital. Juan’s story illustrates the problems faced the world over by mental health service users: a confusing, frightening and often lifelong illness experience; loss of productivity; stigma and social exclusion; difficulties in accessing services; fragmented care provision oriented mainly to treating exacerbations and controlling
behaviour; occasional human rights abuses; and limited advocacy. Mental health problems account for 13% of the global burden of disease, but the gap between need and provision of care is high. Around 80% of people with severe mental disorders in lowand middle-income countries, and 40% in high-income countries, had received no treatment in the previous 12 months. The 224-page report offers detailed examples of best practice in integrated care from 12 countries. These examples show that, even though current provision of mental health services in primary care is still globally far from ideal, integration between primary, secondary and voluntary-sector care can be achieved in a range of settings and socio-economic contexts. The advantages of an integrated approach, in which patients’ first point of contact is their primary health care team, include: . . .
. . .
. . . .
reduced stigma for mental health patients and their families greatly improved access to care more holistic management of co-morbidities including HIV/AIDS, cancer, diabetes, and tuberculosis improved prevention and early detection of mental health disorders better treatment and follow-up of mental disorders, not least because of reduced losses to follow-up lower patient-borne costs (e.g. transport to hospital and loss of productivity in relatives who spend time accompanying the patient) easier communication with healthcare providers improved social integration protection of human rights and avoidance of institutionalisation improved overall capacity of the healthcare system to deal with mental health problems.
The report recommends training primary care workers to help them better identify and respond to patients with mental disorders. But it also points out that the effects of training are nearly always short-lived if staff do not practice newly learnt skills and receive specialist supervision over time. Systems of supervision and
82
T Greenhalgh
ongoing support for primary care workers are strongly recommended in addition to initial training. The report recognises that in order for its recommendations to be effective, the overall workload of primary care staff must be addressed. In many countries, such staff are overburdened with work as they are expected to deliver multiple programmes with limited resources and backup. There may be a need to increase the numbers of primary health care staff if they are to take on the additional burden of mental health work and deliver potential in this area. As with all complex challenges in health and social care, there is no simple or universal formula for providing an effective and efficient integrated mental health service. But ten principles set out in the report
provide some high-level guidance for countries seeking to achieve this goal. These range from clear and coherent national-level policy direction and adequate resource allocation through to grass-roots involvement and capacity building at local level. ADDRESS FOR CORRESPONDENCE
Professor Trisha Greenhalgh 206 Holborn Union Building Highgate Hill London N19 5LW UK Email: [email protected]
# 2009 Royal College of General Practitioners
London Landscape
WHO/WONCA report – Integrating Mental Health in Primary Care: A Global Perspective Trisha Greenhalgh Professor of Primary Health Care, London, UK
At the WONCA Asia Pacific annual conference in Melbourne, October 2008, WONCA President Chris Van Weel introduced what he called a ‘historic moment’. Four years in gestation and involving input from 12 countries in four continents, the joint WHO/WONCA report Integrating Mental Health in Primary Care - A Global Perspective was finally being launched. The 800 free copies were snapped up by delegates before the end of morning coffee (and disappointed latecomers were told they could download a pdf of the full report from www.who.int/mental_health/policy/en). Dr Michelle Funk, co-ordinator of Mental Health Services at WHO Geneva, introduced the report by reading the story of Juan, a 43-year-old man from a South American country who had developed schizophrenia in his mid-20s. Juan described how his life disintegrated soon after his diagnosis, with the loss of his job, a failed marriage, loss of contact with his children, and returning to live with his elderly mother who did her best under difficult circumstances. Juan received many years of hospital-based ‘treatment’, which typically took him away from his home and family and included numerous inpatient episodes which, despite ‘nice’ staff, he experienced as traumatic. He was sometimes made to receive treatment he didn’t want or understand, and went hungry because the food in hospital was inadequate. When discharged, Juan often missed his outpatient appointments (and hence his injections) because he could not afford the bus fare to the city. But the story had a relatively happy ending: Juan now receives his regular medication in a community based clinic three blocks from his home, from a nurse he knows and likes. He feels understood and supported, and looks forward to his fortnightly visits to the clinic. He’s currently well, but if he develops problems, he will be able to see a psychiatric nurse at a community outreach clinic without the need for a trip to hospital. Juan’s story illustrates the problems faced the world over by mental health service users: a confusing, frightening and often lifelong illness experience; loss of productivity; stigma and social exclusion; difficulties in accessing services; fragmented care provision oriented mainly to treating exacerbations and controlling
behaviour; occasional human rights abuses; and limited advocacy. Mental health problems account for 13% of the global burden of disease, but the gap between need and provision of care is high. Around 80% of people with severe mental disorders in lowand middle-income countries, and 40% in high-income countries, had received no treatment in the previous 12 months. The 224-page report offers detailed examples of best practice in integrated care from 12 countries. These examples show that, even though current provision of mental health services in primary care is still globally far from ideal, integration between primary, secondary and voluntary-sector care can be achieved in a range of settings and socio-economic contexts. The advantages of an integrated approach, in which patients’ first point of contact is their primary health care team, include: . . .
. . .
. . . .
reduced stigma for mental health patients and their families greatly improved access to care more holistic management of co-morbidities including HIV/AIDS, cancer, diabetes, and tuberculosis improved prevention and early detection of mental health disorders better treatment and follow-up of mental disorders, not least because of reduced losses to follow-up lower patient-borne costs (e.g. transport to hospital and loss of productivity in relatives who spend time accompanying the patient) easier communication with healthcare providers improved social integration protection of human rights and avoidance of institutionalisation improved overall capacity of the healthcare system to deal with mental health problems.
The report recommends training primary care workers to help them better identify and respond to patients with mental disorders. But it also points out that the effects of training are nearly always short-lived if staff do not practice newly learnt skills and receive specialist supervision over time. Systems of supervision and
82
T Greenhalgh
ongoing support for primary care workers are strongly recommended in addition to initial training. The report recognises that in order for its recommendations to be effective, the overall workload of primary care staff must be addressed. In many countries, such staff are overburdened with work as they are expected to deliver multiple programmes with limited resources and backup. There may be a need to increase the numbers of primary health care staff if they are to take on the additional burden of mental health work and deliver potential in this area. As with all complex challenges in health and social care, there is no simple or universal formula for providing an effective and efficient integrated mental health service. But ten principles set out in the report
provide some high-level guidance for countries seeking to achieve this goal. These range from clear and coherent national-level policy direction and adequate resource allocation through to grass-roots involvement and capacity building at local level. ADDRESS FOR CORRESPONDENCE
Professor Trisha Greenhalgh 206 Holborn Union Building Highgate Hill London N19 5LW UK Email: [email protected]
