Has implementation of integrated mental health services in primary care programs positively impacted health outcomes among the mentally ill in developing countries?
Mental health is a crucial component of overall well-being, yet it is often neglected or stigmatized in many developing countries. According to the World Health Organization (WHO), one in four people in the world will be affected by a mental or neurological disorder at some point in their lives, and around 450 million people currently suffer from such conditions. However, most of these people live in low- and middle-income countries (LMICs) where there is a lack of resources, trained personnel, and awareness to address their mental health needs. As a result, many people with mental disorders do not receive adequate care, or face discrimination and human rights violations.
One way to improve the access and quality of mental health care in LMICs is to integrate it into primary care settings, where most people seek health services. Primary care is the first level of contact with the health system, and it provides comprehensive, continuous, and coordinated care for individuals and communities. Integrating mental health into primary care means that mental health services are delivered by primary care workers who are trained and supervised by mental health specialists, and that mental health is included in the policies, plans, and budgets of the primary health system.
There is evidence that integrating mental health into primary care can have positive impacts on health outcomes among the mentally ill in developing countries. A systematic review by Rahman et al. (2013) found that task-shifting interventions, where non-specialist health workers deliver psychological treatments under supervision, can be effective for common mental disorders such as depression, anxiety, and post-traumatic stress disorder in LMICs. Another systematic review by Chisholm et al. (2016) found that integrating mental health into primary care can be cost-effective and affordable for LMICs, especially when combined with measures to reduce the treatment gap, such as increasing the availability of psychotropic drugs and strengthening referral systems.
However, there are also challenges and barriers to implementing integrated mental health services in primary care programs in developing countries. These include the lack of political commitment and funding, the shortage and high turnover of human resources, the low awareness and stigma of mental disorders among the population and health workers, the poor quality and supervision of mental health services, and the weak monitoring and evaluation systems. Therefore, it is important to adopt a context-specific and evidence-based approach to designing and implementing integrated mental health services in primary care programs in developing countries.
One example of such an approach is the PRIME (PRogramme for Improving Mental health carE) project, which aims to generate evidence on how to implement and scale up integrated mental health services in primary care in five LMICs: Ethiopia, India, Nepal, South Africa, and Uganda. The project involves developing, piloting, and evaluating district-level mental health care plans that are based on a situational analysis, stakeholder engagement, theory of change, and intervention packages for priority mental disorders. The project also involves costing the interventions, assessing their impact on health outcomes and service use, and identifying the factors that facilitate or hinder their implementation.
The PRIME project has produced several publications that describe the development and evaluation of the district mental health care plans in each country. These publications can be found on the PRIME website (www.prime.uct.ac.za) and on the British Journal of Psychiatry supplement (Lund et al., 2016). Some of the common findings from these publications are that integrating mental health into primary care requires a multi-faceted and collaborative approach that involves policy-makers, managers, providers, users, and carers; that there is no one-size-fits-all model for integration, but rather a range of options that can be adapted to different contexts; and that there are gaps in the evidence base for some aspects of integration, such as the optimal mix of human resources, the best strategies for supervision and referral, and the long-term effects on health outcomes.
In conclusion, integrating mental health into primary care can be a feasible and effective way to improve the access and quality of mental health care in developing countries. However, it also requires overcoming several challenges and barriers that vary across different settings. Therefore, it is important to adopt a context-specific and evidence-based approach to designing and implementing integrated mental health services in primary care programs in developing countries.
References:
Chisholm D., Lund C., Saxena S. (2016). Cost of scaling up mental healthcare in low- and middle-income countries. The British Journal of Psychiatry 208(s56): s55-s62.
Lund C., Tomlinson M., Patel V. (eds.) (2016). Integration of Mental Health into Primary Care in Low-Resource Settings: Lessons Learned from PRIME. The British Journal of Psychiatry 208(s56).
Rahman A., Fisher J., Bower P., Luchters S., Tran T., Yasamy M.T., Saxena S., Waheed W. (2013). Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis. Bulletin of the World Health Organization 91: 593-601I.
