Integrating Mental Health and Primary Care: Lessons Learned in Different Countries
Report on a workshop held at WONCA Prague
After positioning the workshop into ongoing work of WONCA and the World Health Organization, presenters illustrated efforts to improve the care and health of people with emotional and behavioral problems with contemporary examples from the Czech Republic, the Netherlands, Australia, Hong Kong, New Zealand, and the United States. These examples spanned policy and practice and ranged from screening systems and information exchange strategies to redesigned practice systems with revised roles and business models. Some 40 participants from many countries then energetically shared additional actions underway and their thinking about them. The workshop organisers subsequently individually listed important themes and together distilled them into the following summary. The purpose of this summary is not to be exhaustive or prescriptive, but rather to (1) remove from consideration mistaken notions that these problems are unimportant and of little interest to family doctors and (2) further stimulate continuing worldwide efforts to help people with prevalent emotional and behavioral problems get proper care.
Theme 1: Mental and physical health are inseparable in family medicine and a very big deal everywhere.
Across the world, family doctors’ days are filled with patients with emotional and behavioral issues of varying intensity and variable amenity to achievable interventions in local communities. While the exact ways people present and experience these problems to their health care systems differ, there seem to be many commonalities across countries and cultures.
Proper classification of patients and their problems remains a very big problem for family doctors and merits much more attention as foundational, intellectual work essential to more rapid progress. The present classification and coding procedures seem to both over and under “diagnose” patients’ problems. Substance misuse seems to “run with it all.” Patients with emotional and behavioral problems need to be looked at as "one whole person" rather than as a sum of distinctive ailments.
There is a need to move away from an emphasis on patients’ and practices’ limitations to their potential, acknowledging that life is often complicated; and health, emotional and social problems often combine into very complex situations that require adjustments to practices and to individuals’ needs, preferences, and capacities. This entire situation is ripe for world-wide attention by family doctors in community and academic settings.
Theme 2: There is a disturbing mismatch between the resources needed to help patients with emotional and behavioral problems, and what is available in routine frontline practice across the world in both richer and poorer countries.
One reason for a mismatch is the over-medicalisation of some problems and the failure to “normalise" the ebb and flow of a lifespan. De-medicalisation of some mental symptoms appears to be an explicit task of family physicians and primary care more generally. There is also a plethora of screening and detection tools for use by family doctors, and a deficiency of capacity to respond properly to what is found. Nurses and other clinically trained staff who are co-located within family practices can increase efficiency and enhance services as part of a practice team that focuses on patient centered care and shared decision-making, rather than “my terrain” and “my protocol.”
In general medical practice, it is important for the doctor to devote enough time for listening to patients’ stories concerning their mental state and knowing their personal narrative, not just various people asking questions again and again. It is the story that creates shared understanding among patients, families, the health care system, and communities—and this is often more important than diagnosis and treatment.
The business models of family doctors worldwide do not support and sustain the provision of care needed, especially if there is not a major problem present – for example low mood, acute stress, anxiety related to hard life conditions. Reimbursement mechanisms and prescribing drive labeling, e.g. low mood becomes depression; and a change in local payment mechanisms can erase or create an epidemic. There is a “tyranny of payment models” that seems to be holding back progress. Community-based systems are viewed by many as “better” than hospital-based models. The proper use of “lower-cost” labor is a promising strategy to make care for emotional and behavioral problems affordable. Given the inseparability of mental and physical problems, it seems the claim that family doctors are not paid to treat emotional and behavioral problems is “oxymoronic.” There is consensus that redesigned care for people with emotional and behavioral problems requires revised, enabling payment systems.
Theme 3: Stigmatisation of people with emotional and behavioral problems seems to be universal, though expressed in different ways and intensity in different settings.
Across countries and cultures, people who have emotional and behavioral problems are too often seen as “different,” in a way that reduces them as persons.
Often, seeking care from the family doctor in a primary care setting is more acceptable to patients and their families than attending a designated mental health clinic of some sort. Careful use of terms and codes can avoid labeling people in ways that can do harm. Neuroscience supports viewing some conditions as brain problems, just as other science views things as kidney or lung problems; and brain problems merit the attention of your family doctor. People with emotional and behavioral problems often have other conditions that benefit from a comprehensive approach that is seen as “regular” health care. Integration of care in the primary care setting can be an antidote to stigmatization.
Theme 4: While health is a community affair and health care a team sport, patients desire, expect, and need someone to be an authoritative, organizing force—responsive and responsible to them as they deal with their problems.
Family doctors can be such a person because they retain a focus on over-all health, not just a particular disease; and this distinguishes in many instances family doctors’ thinking and approaches from psychiatrists’ and other clinical specialists’. Stratification of care according to severity makes sense in many situations and prompts consideration of information exchange and linkages between primary, secondary, and tertiary care. Continuity of care across these levels is a big challenge, and emerging information systems and inter-professional willingness to collaborate make improvements possible.
It is typically not easy to unite various and often useful perspectives into a proper, achievable approach to helping people with emotional and behavioral problems. In too many cases, it is no one’s job to do the “uniting.” However, as exemplified by presentations and commentary at this WONCA workshop, there are many examples of progress. This situation represents an immediate, important, practical opportunity for family doctors worldwide to make a further difference in the lives of their patients and communities.
Chris van Weel
Evelyn van Weel - Baumgarten
Larry A Green