Response to mental health crisis needs to start with primary health care
Primary health care (PHC) brings comprehensive health care closer to people and a PHC provider is oftentimes the first health point of contact. Mental health care, delivered through PHC, has been demonstrated to increase access to care in a cost-effective way, reduce stigma associated with mental illness, improve social integration, and decrease the number of referrals to secondary level care. Despite this evidence, the diagnosis and treatment gap remain incredibly wide and has been exacerbated by COVID-19.
The views expressed are those of the author and do not necessarily
reflect the position of Re:solve Global Health.
Mental health disorders affect more than one billion people around the world. The global case numbers are staggering: 266 million people living with anxiety disorders, 253 million with depressive disorders, 170 million with substance use disorders, and 20 million living with schizophrenia. Despite these staggering numbers, an astonishing 70% of those who need mental health care lack access to high-quality services.
Access to diagnosis, treatment and referral for people living with mental health disorders is especially challenging in low- and middle-income countries (LMICs). Because of this, a large proportion of individuals who live far from a specialized treatment facility are left to live without treatment. This reality leaves them at greater risk for educational and work difficulties, vulnerabilities to social problems, isolation, and high rates of substance abuse, self-harm, and suicide.
The treatment gap is the result of many factors including stigma, health care worker shortages, and lack of access to training, leading to low detection rates and low prioritization given to these conditions. Health systems in LMICs also suffer from fragmented service delivery models; limited capacity for local research, advocacy, and policy change; and limited funding to sustainably scale proven models.
The COVID-19 pandemic has further disrupted service delivery and access to mental health care services. According to a recent WHO survey, COVID-19 has disrupted or halted existing critical mental health care services in 93% of countries worldwide. Reduced access to mental health care services also impacts health-seeking behavior or adherence to care regimens for other health conditions (e.g., diabetes, tuberculosis, HIV), leading to poorer health outcomes. Pre-existing access challenges and the increasing demand due to COVID-19 related grief and stress has compounded the need for mental health care services.
Integrating care at the primary health level
PATH, an international NGO with programs in over 70 countries, has witnessed huge unmet need in the communities where we work, and has prioritized integrating elements of mental health care into existing programs at the PHC level.
PHC is not restricted to managing illness, but also includes disease prevention and health promotion. Therefore, it is critical for the mandate of PHC to include screening and management of mental health disorders. Having dedicated specialists for mental health disorders may not be feasible within the resource constraints of health systems in LMICs. However, task-shifting to community-based and lay providers, integrating light-touch mental health screening and counseling into existing health services, and strengthening referrals between primary and tertiary/specialized services can help support the delivery of such services as a component of PHC. Screening, diagnosing, and treating a mental health disorder alongside someone’s pregnancy, HIV, or diabetes related visit, leads to increased efficiency of care and improved outcomes for both conditions. Several PATH projects in LMICs have highlighted the value of integrating mental health care services in the PHC setting.
Mental health & HIV (Vietnam)
People living with, or affected by, HIV have an increased risk of mental health morbidity. This double burden can not only reduce quality of life but lead to difficulties adhering to and continuing antiretroviral therapy (ART) for people living with HIV (PLHIV) or pre-exposure prophylaxis (PrEP) to prevent HIV among those who are HIV negative. Through the USAID/PATH Healthy Markets (HM) project in Vietnam, we incorporated mental health care into existing HIV services.
The project partners with trusted peer outreach workers to begin conversations around mental health and refer clients to community led PHC clinics for further evaluation. There, trained service providers screen clients for depression, anxiety, addiction, and suicide risk and help tailor care plans and a stepped care approach to needed services – individual and group supportive counseling, psychoeducation, problem-solving cognitive-behavioral interventions, or referrals to expert psychiatric care. In just eight months, more than 1,700 key population clients were linked to mental health care services at five HM supported sites. Learn more
Mental health & maternal health (Mozambique)
Postpartum depression (PPD) is an often-neglected public health issue in LMICs, with the estimated prevalence of 20% being almost double that of developed countries. Mothers with PPD can face challenges breastfeeding, bonding with their baby, increased anxiety, isolation, and decreased self-care and healing post-delivery. To address this problem, PATH worked with the Maternal and Mental Health Departments at the Ministry of Health of Mozambique (MOH), to develop and pilot the first ever protocol for screening and management of PPD within routine postnatal care (PNC). Mothers valued the intervention, and they were motivated to return to the health facility after being screened for PPD. Mental health practitioners confirmed more than 70% of suspected cases of PPD that maternal/child health nurses referred to them. Nurses felt the intervention was within the scope of their duties, and they were keen to continue with the task. Several nurses highlighted the special importance of the intervention for adolescent mothers, who are at higher risk of depression. Learn more
Mental health & primary health care promotion (India)
In addition to screening and treatment services, the PHC continuum of care includes health promotion activities. A primary target of these health promotion messages and activities is adolescents – a challenging age group to reach. This is particularly troubling because up to 75% of all mental health disorders have their origins in adolescence and young adulthood and, already, there is an incredible treatment gap for mental illness in India (as high as 83% for all age groups). PATH embarked on a human-centered design project, in partnership with young people, to help create an appropriate, accessible, and safe approach to support youth mental health care. The goal is to develop a mental health promotion intervention, integrated into the PHC system, that is responsive to the cultural context, and increases screening services, treatment uptake, engagement and satisfaction. Learn more
Now is the time
As momentum builds for universal health coverage and bolstering of PHC systems, we must provide better mental health care to the millions that need it. The current detection and treatment gap for mental health disorders is simply unacceptable. Evidence-based interventions that are based on contextually appropriate use of task-sharing and smart application of technology-based solutions, can go a long way in improving the availability of and access to effective mental healthcare, including in low resource settings.
Vertical funding for some specific disease areas has been monumental, but, in many cases, has also made it difficult for countries to support even investments across the entire health system. People do not experience their health vertically, nor is their mental health an “add-on.” We call on governments, foundations, investors, and private sector companies to invest in integration of mental health in primary health care. It is time to prioritize these large unmet needs; otherwise, we will continue to fail people living with mental health needs globally.