Professional Documents
Culture Documents
PETER VENTEVOGEL
Abstract
Since 2008 the World Health Organization (WHO), through its mental health Gap Action Programme, has attempted to
revitalize efforts to integrate mental health into non-specialized (e.g. primary) healthcare. While this has led to renewed
interest in this potential method of mental health service delivery, it has also prompted criticism. Some concerns raised are
that it would contribute to the medicalization of social and psychological problems, and narrowly focus on primary care
without sufficient attention given to strengthening other levels of the healthcare system, notably community-based care and
care on district levels. This paper discusses seven elements that may be critical to preventing inadvertently contributing to
increasing a narrow biomedical approach to mental healthcare when integrating mental health into non-specialized healthcare: (1) using task shifting approaches within a system of stepped care, (2) ensuring primary mental healthcare also includes
brief psychotherapeutic interventions, (3) promote community-based recovery-oriented interventions for people with disabling chronic mental disorders, (4) conceptualizing training as a continuous process of strengthening clinical competencies
through supervision, (5) engaging communities as partners in psychosocial interventions, (6) embedding shifts to primary
mental healthcare within wider health policy reforms, and (7) promoting inter-sectoral approaches to address social determinants of mental health.
patients (Saxena et al., 2007). Moreover, the specialist academic training of psychiatrists is likely to
put them in an antagonistic position to most of their
clients, who use various explanatory models for
mental health problems that are not easily compatible with those of academic psychiatry (Kleinman,
2012).
Therefore, integration of mental health interventions within primary care systems has the advantage
of being more accessible and also recognizes that
people with mental disorders also often have significant acute and chronic physical health problems that
may lead to worse health outcomes (Moussavi et al.,
2007). Additionally, many people with (undetected)
mental disorders will initially visit general healthcare
providers as a gateway to care. As a result, integrating
mental healthcare into non-specialized healthcare
can optimize both mental health and physical health
outcomes, and avoid fragmentation of health services
(Patel et al., 2013). Another common concern,
addressed by integrating care of mental health needs
into the context of general care settings, is the stigmatization that may be associated with specialized
settings for psychiatric care as general care settings
are often more acceptable to patients and family
members (Goldberg et al., 2013).
Correspondence: Peter Ventevogel, Public Health Section, Division of Management and Programme Support, UNHCR, Geneva. 94 Rue de Montbrillant,
1202, Geneva, Switzerland. E-mail: peter@peterventevogel.com
(Received 31 August 2014 ; accepted 12 September 2014 )
ISSN 09540261 print/ISSN 13691627 online 2014 Institute of Psychiatry
DOI: 10.3109/09540261.2014.966067
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P. Ventevogel
Methods
This paper synthesizes the literature around the
integration of mental health into primary care in
low- and middle-income countries. English language
literature was retrieved through searches in MEDLINE and Google Scholar using combined search
terms such as integration, primary health care
mental health, low- and middle-income countries,
Asia, Africa, Middle East, Latin America, and by
scrutinizing the reference lists of retrieved articles
and papers.
Expansion of mental health services in developing countries is overdue. This will only take
place if tasks of mental health care are undertaken by a wide range of non-specialist health
workers, including those responsible for primary
health care; and services are directed initially
at a very limited range of priority conditions.
(Giel & Harding, 1976).
The idea of inclusive primary healthcare services, in
which psychological and social aspects of health are
considered side by side with somatic aspects, has
been enshrined in various landmark documents such
as the 1977 Declaration of Alma Ata on primary
healthcare and publications of the World Health
Organization (WHO, 1990, 2001; WHO & WONCA,
2008). All of these initiatives emphasize that to
improve coverage of mental health services it is vital
for primary care workers to be trained in recognition
and management of mental disorders, complemented
by a system of on-going supervision and support.
Despite repeated calls to integrate mental health
into primary care, the reality is that in most regions
of the world regular primary healthcare services have
disappointingly little if anything to offer most
people with mental disorders (de Jong, in press;
Greenhalgh, 2008; Rohde et al., 2008; Wang et al.,
2007). Most people with serious mental disorders in
low-income countries still do not receive any treatment at all, at least not within the formal healthcare
sector (WHO World Mental Health Survey Consortium, 2004). There have been dozens of seemingly
effective initiatives within low-income countries to
treat psychosis, depression, and other conditions
within primary care, but almost none have been
sustained or scaled up to reach a larger coverage
area (Kleinman, 2013). Programmes that started
promisingly and had impressive results could not be
sustained after external funding ended as national
governments or local partners were unable or
unwilling to continue (Schulsinger & Jablensky,
1991). In some of the few cases where sustainable
programmes existed, newly erupting armed conflict
disrupted services (de Jong, 1996).
Against this backdrop, the WHO started a renewed
initiative to close the treatment gap: the mental health
Gap Action Programme (mhGAP) (WHO, 2008). A
major component of this programme is the integration of mental health services into primary care as
the most viable way of closing the treatment gap and
ensuring that people get the mental health care they
need (WHO & WONCA, 2008, p. 1).
mhGAP: revitalizing primary mental healthcare
The Mental Health Global Action Programme
(WHO, 2008) aims to scale up evidence-based
Moderate-severe depression
Psychosis
Bipolar disorder
Epilepsy/seizures
Developmental disorders
Behavioural disorders
Dementia
Alcohol use and alcohol use disorders
Drug use and drug use disorders
Self-harm/suicide
Conditions specifically related to stress
Other significant emotional and medically unexplained
complaints
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Policy support
Successful experiences with mental health integration highlight the role of supportive national health
policies and the inclusion of mental health into minimum packages of care for primary care facilities
(Kigozi & Ssebunnya, 2009; Mbatia & Jenkins, 2010).
In many countries the integration of mental health
into primary care has been a policy objective, but
remained window-dressing as long as no specific
allocation of resources were made to implement it
and while governments continue not to see mental
health as a real priority. Within the emerging field
of global health the attention to mental health is
growing, among financial donors, governments and
researchers (Patel & Prince, 2010). A major reason
for this rising focus is the increasing domination
of the global disease burden by chronic, noncommunicable diseases, including mental neurological and substance use disorders (Beaglehole & Bonita,
2008). This has, however, not yet been translated
into a proportional allocation of funds or other
resources (Becker & Kleinman, 2013; Bolton, 2014),
although several countries (including Brazil, India,
South Africa and China) have increased public
resource allocation for mental healthcare, with a
strong emphasis on integration into primary care
delivery systems (Eaton et al., 2011).
In order to ensure a holistic mental healthcare at
primary level, it is essential that the supportive structures on other levels of the health systems are also
strengthened. For example, the appointment of
dedicated focal points for mental health on district
and provincial levels may help to coordinate mental
health services and contribute to the inclusion of
mental health within district and provincial strategies, training plans and resource allocation (WHO &
WONCA, 2008). On all policy levels, and across
multiple sectors, mental health should be considered
an integral element of any health system. On a
national level, this requires inclusion of mental health
into general health policies and strategies, and in
training centres for health cadres.
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