Integrating Mental Health Services into Primary Care

Dr. Jibril Handuleh Amoud University

Mental health in GP practice Mental illness is covert or hidden Primary carers fail to recognize one

out of two patients with mental illnesses

Incidence of mental illness varies in different areas and practices and at different times

Untreated mental illness is time-consuming and costly

The cost of untreated mental illness:WHO “Burden of Disease” study To patient

Morbidity, mortality, financial, productivity, family suffering, reputation

To community Productivity, financial, loss of

community cohesion To doctor

?

Obstacles to mental health diagnosis Patient

Ignorance, stigma, fear of the implications, lack of finances or resources to treat

Doctor Knowledge and/or skill deficit,

attitude, misinterpretation or interest issues, lack of facilities and resources, time, remuneration issues, discomfort with emotional issues (personal or cultural)

Society Different priorities, financial, lack of

community education, health policy, community attitudes

What are the challenges in Somaliland/Somalia practice???

Association Between Physical & Mental Problems in Primary Care Patients

10-20% of general population will seek primary care for a MH problem

Studies show prevalence of mental health problems: PRIME-MD: average 26% have psychiatric

disorder while another 13% have significant functional impairment

WHO: average of 21% had psychiatric disorders

2/3 of primary care patients with psychiatric diagnosis have significant physical illness

COPYRIGHT © IAN M CHUNG 2005

The GP perspective General practice is total (bio-psycho-social)

and should address continuing patient care in the context of their family and community

The GP has an ongoing relationship with the patient and their family

General practice provides opportunity for early diagnosis before the condition is well-defined or fully developed

The GP sees the patient before they are “educated” by the process of investigation and elimination

COPYRIGHT © IAN M CHUNG 2005

The main mental illnesses seen in General Practice Depression and anxiety are the major mental

illnesses, alone or co-morbid, or as manifestations of other mental conditions or medical illness

Both depression and anxiety have a range of severity and forms

Specificity of diagnosis is important Somatisation is very common: the mind and body

are one also patient prefers to c/o an illness Drug use and illness must be excluded Any illness the GP needs to consider the full

circumstances of the patient

Association Between Physical & Mental Problems in Primary Care Patients

Chronic medical illness increases probability of depression by two to three folds

Psychiatric disorders in primary care are less severe than those in MH settings

Health status, quality of life, functional status-better correlated with psychosocial factors than physical disease severity

Medical Outcome Study (MOS) indicates functional impairment due to depression compares to that of COPD, diabetes, CAD, hypertension, and arthritis

Recognition & Treatment of MH Problems in Primary Care

1/2-2/3 of patients meeting criteria for psychiatric diagnosis go unrecognized by primary care providers

Even when recognized & treated, dosage & duration of antidepressant meds are usually inadequate

In naturalistic studies, there was no difference in outcome between treated and untreated depressed patients in primary care setting.

Health Care Utilization

Studies indicate objective disability or morbidity alone can predict only 10-25% of health care use

One study found 60% of all medical visits were by “worried well” with no diagnosable disorder

Patients with MH problems, when compared to unaffected counterparts, use twice the medical resources.

Patients with somatization disorder use 9 times national norm of medical resources

Why Should Primary Care Providers Integrate MH Services Into Primary Care?

Primary Care Providers deal with patient’s untreated psychological problem- identified or not

Psychosocial/behavioral problems take up Primary Care Provider time regardless of degree to which problems are explicit focus of practice

1/3-1/2 of Primary Care patients will refuse referral to MH professional

Why Should Primary Care Providers Integrate MH Services Into Primary Care?

Patients who refuse referral tend to be high utilizers with unexplained physical symptoms

Dichotomizing patients problems into physical & mental leads to: Duplication of effort Undermines comprehensiveness of care Hamstrings clinicians with incomplete data Insures that the patient cannot be completely understood

Why Should Primary Care Providers Integrate Mental Health Services Into Primary Care?

Many prefer to receive MH services in Primary Care because not construed as “mental healthcare”

With expectation of seriously mentally ill, basic MH services can be managed in Primary Care setting

Growing evidence that integrated primary care is cost-effective

Conclusions

Mental healthcare cannot be divorced from primary medical care - all attempts to do so are doomed to failure

Primary care cannot be practiced without addressing mental health concerns, and all attempts to neglect them will result in inferior care

deGruy, F.V. (1997). Mental healthcare in the primary care setting:

A paradigm problem. Fam. Syst. & Health 15:3-26.

Barriers to Providing Mental Health Services to Primary Care Patients

Competing Demands and Tasks of Primary Care Providers

Average primary care visit last 13 minutes Patients have average of 6 problems on problem list Inadequate time to adequately assess for mental health

problems and manage once assessed A zero-sum game. No room for provision of new services

without eliminating another or adding resources for additional work

Barriers to Providing Mental Health Services to Primary Care Patients

Limitations of Specialty Mental Health Service for Primary Care Setting Focus of Psychiatry is increasingly on diagnosis of seriously

disturbed patients and prescription/monitoring of psychotropic medication

Psychiatric diagnostic systems that do not fit clinical phenomenology

Mental Health Providers not trained to address psychological/behavioral problems common in primary care settings somatization chronic pain noncompliance with medical regimens

Barriers to Providing Mental Health Services to Primary Care Patients

Patient Barriers to Providing Mental Health Services Concerns about stigma of psychiatric diagnosis Significant negative consequences for pursing mental health

care Domestic abuse Criticism from family

Patient Somatization: Problems not perceived as psychological

Patient has no psychiatric diagnosis, but still in need of psychological care

Conclusion

“The problem of underdiagnosis and undertreatment cannot be remedied by simple provision of guidelines and protocols, no matter how elegant; it will require a reordering of the actual structure and process of primary care.”

deGruy, F.V. (1997). Mental healthcare in the primary care setting:

A paradigm problem. Fam. Syst. & Health 15:3-26.

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level One: Minimal Collaboration - Providers in Separate Locations

Separate systems Rarely communicate about patients Most private practices and agencies Handles adequately problems with little biopsychosocial

interplay & few management difficulties Handles inadequately problems that are refractory to treatment

or have significant biopsychosocial interplay

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level Two: Basic Collaboration on Site

Separate systems but share same facility No systematic approach to collaboration - do not share common

language or in-depth understanding of each other’s worlds. Misunderstandings are common

Common in mental health settings Handles adequately problems with moderate bio-psycho- social

interplay requiring occasional communication about shared patients

Handles inadequately patients with ongoing and challenging management problems

Models of Collaboration Between Primary Care and Mental Health Care Providers

Level Three: Close Collaboration in Fully Integrated System Same site, same vision, and same system in a seamless

web of biopsychosocial services

Staff committed to biopsychosocial systems paradigm. In-depth understand of each other’s roles/cultures. Operates as a team - regular collaboration

Models of Collaboration Between Primary Care and Mental Health Care Providers

Continued... Level Three: Close Collaboration in Fully Integrated System

Fairly rare. Occurs in some hospice centers and special training and clinical settings.

Handles adequately most difficult and complex biopsychosocial problems with challenging management problems

Handles inadequately problems when resources of health care team are insufficient or when there is breakdown with larger service system

Somaliland/Somalia Mental heath integration into primary health care There is poor primary health care

level at MCHs and hospital facilities. Mental health services are not well

developed and there is no integration at this time.

Somaliland has one of the highest mental health disorders prevalence worldwide.

.

Global efforts In 2008, WHO developed the

MHGAP curriculum guide for the low and middle income countries.

Several countries have now adopted it for primary care physicians.

Amoud medical school will give the guide as part of mental health undergraduate teaching in January 2012.

MH Gap Guide addresses Depression Psychosis Schizophrenia Mania Alcohol and substance misuse Suicide Assessment sheets Cognitive disorders

Mental health and physicians Primary care physicians don’t have

mental health education after leaving medical school.

Primary care physicians meet with psychiatric patients suffering from co-morbid medical conditions.

Some try meds usually without psychiatric assessment

Psychiatry in Borama There was psychiatric reference till

before 2011. Physicians were not interested in

mental health as general. Psychiatric service was not

existing. Patients were not taken to hospitals

as there was nothing for MH

How we can address mental health Integration of MH into primary

health care Referring hard cases into

psychiatric practice. Workshops and CME on mental

health for physicians

Somaliland Somaliland mental health service is

restricted. Mental health ward is located in

Hargeisa now run by GRT Former prison in Berbera is the

mental hospital in Berbera Mental health OPD and inpatient

ward in Burao Mental health OPD in Borama

Other towns in Somaliland have no mental health services.

Traditional healers centers named centers of care receive so many patients they use herbal medication, beating and residential rooms to keep patients in.

No mental health policy No mental health integration policy yet.

Mental health education Amoud and Hargeisa medical schools

have their undergraduate curriculum developed.

Given in the sixth year by the King’s College London in support with THET.

Distance learning support in mental health teaching for medical students , interns and junior doctors on www.medicineafrica.com

Amoud mental health teaching Dr. Jibril Handuleh developed OPD

for mental health teaching and patient care.

Dr. Handuleh is also Somaliland coordinator for medicineafrica.

The teaching is offered for nurse and medical students since April 2011.

Case presentations, class room teachings and community mental health service is given in Amoud

This service is also introducing mental health gap curriculum into Somaliland mental health education for medical students.

Puntland Mental health services in Bosaso Galkacayo Garowe Traditional healer centers exist No medical schools Most of the work is done by GRT

South/central Somalia Mental wards Traditional healers Dr. Habeb center is the most

common mental health ward in Mugadishu.

Some are scattered in places like Marca etc.

Refer the WHO mental health situational analysis, Feb, 2011

No undergraduate psychiatric teaching and online support compared to Somaliland.

THET and King’s College only operate in Somaliland.

Given the civil war, famine and the refugees , the problem is much bigger in the south/central Somalia compared to relatively stable regions.

Mental health in Borama Borama had two hospitals at the

end of 2010 with no mental health service.

Both hospitals are teaching hospitals for Amoud University school of health sciences.

Students had no site for psychiatric bedside teaching.

Amoud Mental health project

Amoud University started mental health project in Borama.

The medical school asked Dr.Jibril to come with the mandate to develop a mental healith service.

Students were going to Hargeisa to have mental health teaching as a part of undergraduate teaching.

The faculty was interested to develop mental health OPD first to offer patient care and clinical bedside teaching.

Jibril, a former mental health rep ended internship in November 2010.

Amoud University recruited Jibril as clinical teacher next month.

I was already Pathology lecturer and clinical assistant in Psychiatry as part of mental health rep post in both Amoud and Hargeisa medical schools

Background of Amoud mental health service Due to the high demand for

psychiatric patient care and clinical teaching , it was necessary to develop a service.

Jibril agreed to come up with service development plan.

Mental health service To introduce mental health in

Borama a pilot project had to be developed to

Learn mental health pattern in Borama

Raise public awareness for mental health care.

Create suitable environment for student mentoring and supervision.

Mental health and global partnership Pilot mental health project had

been in partnership with King’s college London , Institute of Psychiatry-UK and tropical health and educational trust.

Pilot phase was coordinated with GRT, Italian NGO working in mental health in Hargeisa, Berbera and some parts of Puntland

Peace ware Somaliland and ICT department of the University of Copenhagen, Denmark.

in later stage , started link with EMRO mental health and substance misuse department.

Huge technical input from Keroniski institute of Sweden’s Psychiatrist Dr. Yakoub Aden Abdi

Mental health project components Hospital OPD at Alhayett teaching

hospital Prison mental health Community based psychiatry MCH related Perinatal psychiatry School psychiatry

Hospital based service The only option available was the

development of OPD department as there is no ward in Borama.

Ward is currently being planned in Borama and will take time to develop.

Outpatient and emergency case management

Hospital rotation Saturday and Wednesday were the

two days allocated for OPD. Work was from 7.30- 2 P.M Classes for nurses in the last six

months Classes for med students in the

coming 8 months continuously. Intern mentoring

Patient care at the OPD Integrated into medical OPD Patients receive free consultations Patients are offered medications-

Poor patients only. Follow up of patients Patient education with dedicated

patient education leaflets Good documentation system

Telephone number support in case of emergencies

Working with 2 local NGOs to refer patients for treatment

Link with local volunteer networks bringing in patients

Patients both in the general practice and the MH OPD

Student benefits 2 day bedside teaching Strong clinical supervision Student log books Student assessment sheets 2 whiteboards for teaching Teaching materials in place Student exam preparation and

implementation with KCL faculty.

Teaching OPD nurses and student nurses-CPD session

Achievements 250 patients in the OPD were

received in the hospital OPD alone.

The patients had been receiving free medication and consultations with mental health service.

Patient follow up scheme was successful as 90% of patients came up with follow ups.

Community psychiatry This is the first community based

psychiatry in Somaliland. it has two components A. home visits B. traditional healer link

The community program… Home visits segment is the

cornerstone part of Borama based psychiatry.

Amoud nursing school and concerned citizens are major partners.

Home visits come through demand and service provider commitment.

Home visits Patient home visits take place

almost daily at any time possible. A doctor and a nurse always go to

homes. Telephone follow up exists to trace

the cases down. Local pharmacist was trained to

help give depots and educate patients

Traditional healers Traditional healers link was

established in a desire to reach out patients.

Patients were kept in a house with three Sheikhs using so many sorts of herbal medicines.

They also use water boarding and beating.

In the last visit even chaining pts.

Partnership They agreed upon referring cases. They call our service to provide

mental health assessment and management.

Mental health service follows up patients after discharge.

My work reduced their stay days. Stronger follow up to encourage

mental health service

Perinatal psychiatry Introducing mental health into the

maternal care was crucial in our program.

It is first program again to have such program in the Somaliland.

It has antenatal and Postnatal components in partnership with Amoud nursing school.

Global partners King’s College London, UK with

Perinatal psychiatrist working with me on this.

University of Cape town school of Medicine- South Africa. Technical and academic input in the development of teaching materials.

In the pilot phase Training the trainers in Perinatal

Psychiatry in both antenatal and Postnatal care setting in Borama MCHs

It includes basic assessments Common Perinatal psychiatry

presentations Referral systems Follow ups

Training program Nursing tutors Borama MCH workers It was done in July , 2011 Referral system was introduced Program will start in January 2012 MCH patients with mental illnesses

will be referred to psychiatry practice at the teaching hospital.

Prison service The first of its kind in Somaliland. The program has the following

partners Somaliland ministry of Justice Somaliland Custodial corps Amoud Legal Clinic Borama prison Amoud University

Objectives of prison service Train prison guards on mental health

problems among inmates. Advocate for patient care and

treatment Treating for free inmates with mental

illnesses Training the prison nurse in basic

psychiatric practice Developing referral system

Achievements Over 30 inmates treated Training for prison guards done

within three months through tutorials and on job case scenarios

Referral system is in place In partnership with Amoud legal

clinic , the service offers forensic consultation with Borama court.

School mental health service Again , a major step forward with

mental health in Somaliland. In a study , 19 suicide cases in

Borama were related to untreated depression. Handuleh, J. untreated depression among high school students in Borama, North Somalia, Arab journal of psychiatry, to be published in May 2012.

School mental health service Schools had no formal health

system. Mental health was not even

existing. Students and teachers suffer from

whole sort of mental and neurological problems

Amoud University contacted the local ministry of education office.

The plan was presented Ministry of education approved the

project involvement in schools The project started to work with

school teachers, student union leaders and the headmasters.

Students received patient care at schools. The headmaster of schools turned into outpatients working with parents.

Al-Aqsa school presented with school children.

The other schools will receive the same student assessment and management

Mental health workshop for teachers• It was set to be in July but schools went

into holidays.• The workshop will take place in Mid

December. It will have the following objectives: Teacher training in school mental health

arena Communication skills and student support Identification and referral systems

Lessons learnt Mental health development is

dynamic and very interactive. Patient care improved patient life

and family Community gave huge input and

appreciation Local NGOs , citizens alike were

very encouraging.

Global partnerships Teaching service development Community inputs from prison to

homes. Creating research potentiality Faculty support, GPs and other

players in Amoud University

Challenges Human resources Community based barriers Financial issues Time management

Opportunities Creating leaderships in mental

health among med/nurse students and then at the intern level.

Reaching out villages through visits and nurse education at remote places.

Using Skype and 3G technology in the future.

MANY MORE!!!

Any questions

Thank you very much!