ARTICLE 3
The rationale for integrating mental health care within comprehensive primary care setting Michel Gervais, MD, FRCPC, MBA
In 2008, the World Health Organization (WHO) and the World Organization of Family Doctors (WONCA) published a report entitled Integrating mental health into primary care: A global perspective. Here are the main arguments that were raised for justifying the integration of mental health care within primary care settings.1
The burden of mental disorders is great.
Mental disorders are prevalent worldwide and particularly in primary care settings. Their burden is present in all societies and is especially substantial when they are not treated. They generate a heavy toll of suffering, disabilities and economic hardships, both for individuals who are affected and their families.
Mental and physical health problems are interwoven.
The division between "mental health" and "physical health" is artificial to a large extent. In reality, the symptoms of mental and physical illness coexist, are closely interrelated and influence mutually their evolution. Physical health problems are more prevalent in mentally ill individuals than in the general population, and mental health problems are common in people with physical disorders. The integration of mental health in primary care can offer a more holistic approach of care.
The treatment gap for mental disorders is enormous.
“The global neglect of mental health is well-documented. In most countries, mental health issues are neglected within health care policy and planning, and only limited resources are allocated to mental health services. Moreover, the scant resources that are dedicated to mental health are often inappropriately deployed: most mental health resources are spent on expensive care in psychiatric hospitals rather than on primary care, community care or hospital care near to where people live.”
Not only are mental disorders poorly detected but, when the diagnosis is accurately made, they are not adequately treated either. Primary care for mental health can contribute to close this gap.
Primary care for mental health enhances access.
“Integrating mental health into primary care is the best way of ensuring that people get the mental health care they need.” Primary care settings are closer to home for most people than are specialized services. The collaboration with the stakeholders in the community is easier and more effective. Community outreach is facilitated.
Primary care for mental health promotes respect of human rights.
1 World Health Organization (WHO) and World organization of family doctors (Wonca) 2008. Integrating mental health into primary care: A global perspective. WHO Press, ISBN 978 92 4 156368 0
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“Mental health services delivered in primary care minimize stigma and discrimination.”
Primary care for mental health is affordable and cost effective.
“Primary care services are usually the most affordable option, for both affected individuals and the government.” This is especially true for the most common mental disorders like depression and anxiety disorders.
Primary care for mental health generates good health outcomes.
The majority of people with mental disorders treated in primary health care have good outcomes, particularly when linked to a network of services at secondary level and in the community.
In 2011, The College of Family Physicians of Canada has adopted a position paper which stands at the very core of its strategic vision: A vision for Canada, Family Practice: The Patient’s Medical Home.2 The implementation of a medical home aims at ensuring that every Canadian has access to a family doctor, that the therapeutic contract builds on a long term relationship and that care is provided holistically.
Collaborative care is part of this organizational model and is conveyed through "a team-based care including both inter-professional collaboration (between the family physicians and the other health care professionals) and intra-professional collaboration (between the family physicians and other medical specialists).”
Many key components of the collaborative care model are mentioned: timely access to care, electronic medical and health records, comprehensive continuous care, self-management of care by patients, coordination of care with other providers and community resources, interdisciplinary health care team, etc. The medical home concept uses the principles of chronic disease management and integrates mental health care within a comprehensive primary care setting. These environments offer a range of services delivered by teams or networks of providers, an approach consistent with the vision of the collaborative care for mental health. A key success factor in the approach to chronic diseases is to precisely establish multidisciplinary primary care teams providing high quality services and to better integrate primary and specialty care.3
Several studies show that family medicine clinics treat the largest volume of people who consult for a mental disorder. Family doctors perform an important role in the treatment of mental health disorders4
5 and are often the first point of contact to access services in mental health:6 “This preference for (general practitioners) is due to proximity, greater accessibility, less stigmatization and a holistic approach in which physical problems are also managed.”7 Collaborative mental health care is pertinent
2 The College of Family Physicians of Canada 2011, Position Paper, A vision for Canada, Family Practice: The Patient’s Medical Home, September, p. 1-63
3 Ham, Chris, The ten characteristics of the high-performing chronic care system, Health Economics, Policy and Law, 2010, p. 71- 90
4 Helen-Maria Vasiliadis; Raymond Tempier; Alain Lesage; Nick Kates 2009; General Practice and Mental Health Care:
Determinants of Outpatient Service Use; The Canadian Journal of Psychiatry, July; Vol. 54 (7), p.468-476.
5 Canadian Psychiatric Association (CPA) and the College of Family Physicians of Canada (CFPC) 2011, Position Paper, written by Kates, Nick; G Mazowita, F Lemire, A Jayabarathan, R Bland, P Selby, T Isomura, M Craven, M Gervais, D Audet. The Evolution of Collaborative Mental Health Care in Canada: A Shared Vision for the Future. The Canadian Journal of Psychiatry, volume 56 no.5 (May): 1-10.
6 Imboua, Armelle, Marie-Josée Fleury 2009. Médecins omnipraticiens : pratiques et intégration des soins en santé mentale au Québec. Santé mentale au Québec, volume 34 no.1 : 55-76.
7 Rothman, A.A., Edward H.Wagner 2003. Chronic illness management: What is the role of primary care? Annals of Internal Medicine, volume 138: 256-262.
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for enhancing "relationships between mental health care providers and (general practitioners), and for promoting greater availability and diversity of mental health care services."8
In short, collaborative mental health care models, the Chronic Care Model and the medical home strategic vision, combine themselves very neatly into an emergent population-driven health care system.
8 Fleury, Marie-Josée, Jean-Marie Bamvita, Jacques Tremblay, Alain Lesage 2010. Extent and Determinants of General Practitioner Referrals and Contacts With Mental Health Care Providers. Canadian Journal of Community Mental Health, volume 29 no. 2 (Fall): 113-129.
