Mental Health and Primary Care

Mental Health and Primary Care

The World Health Organization has no one official or strict definition of mental health in that cultural differences, subjective assessments and professional theories combine to determine what mental health is (Wikipedia 2006). Most experts, however, agree that it refers to how effectively and successfully a person functions. If he feels capable and competent, is able to handle normal levels of stress, maintains satisfying relationships, leads a relatively independent life and can recover from difficult situations, he is said to be mentally healthy. Primary care, on the other hand, is extended by a health care provider, who acts as the first point of consultation for patients. It is usually provided by primary care physicians at community health centers as opposed to hospitals. Some call or associate it with general practice and family medicine. General practitioners in the United Kingdom are physicians who have completed four years of post-medical education, including three years work in a hospital and another year in the community. Family medicine in the U.S.A. is a specialty, which requires a minimum residency and a Board certification. Primary care manages diabetes mellitus, chronic obstructive pulmonary disease or COPD, depression and back pain. Primary care physicians usually do family practice, internal medicine, pediatrics and sometime obstetrics and gynecology (Wikipedia).

II. Status of the Primary Mental Health Care Industry

Incidence

The World Health Organization estimated in 2001 that 450 million people suffered from mental or neurological disorder and that 25% of the world population could expect to experience it within their lifetime (Nierenberg 2002). Mental illness is a universal condition, which affects people of all nations of all social, economic, and cultural backgrounds, although the poor suffer most from a lack of the most basic resources for effective treatment. WHO established a broad scope of mental health disorders, which include autism, Alzheimer's disease, schizophrenia, depression, sleep disorders, addiction and substance abuse, bipolar affective disorder, panic, anxiety disorders, mental retardation and epilepsy. Records showed that almost a third of global disability from all diseases is due to mental disorders, with depression as the most severe and affecting more than 120 people worldwide. Depression accounts for 12% of global disability and was expected to increase by 15% in 2020. It is second only to heart disease in fatality. Depression may be highest during the middle age, but research indicates that it the elderly and children are not immune to it and other mental health problems, such as dementia and Alzheimer's. One in 10 persons in the U.S. suffers from some defect or impairment of psychological development or from some behavioral, emotional and depressive disorders. Rural isolation and poverty make the problem worse. The mentally ill confront extra burden if they are poor, which may explain why the U.S. has five times as many mentally ill prisoners as patients in mental hospitals. Changing norms can have adverse effects on one's mental health. Separation from traditional and comfortable social environments, dependence on a cash economy, overcrowding, pollution, increased violence in cities and eating disorders, especially among girls, have had disturbing effects on populations. Mental illness also often leads to or makes other health problems worse. Those who already suffer from untreated mental disorders often also suffer from chronic or serious conditions, such as cancer, HIV / AIDS, heart disease, diabetes or addition to drugs, tobacco or alcohol. Suicide has been the most tragic consequence of mental illness and statistics showed that close to a million people commit suicide every year and that 10 to 20 million would attempt it. Suicide has been found to be preceded by severe depression or schizophrenia. Farmers in the U.S. were said to be 1.5 to twice likelier than other groups of men to commit suicide on account of economic hardship and loss of small farms. Battered women in the U.S. were also reported to be give times likelier to take their own lives than any other groups of women (Nierenberg)

Current Approaches

Available treatment methods for mental illness differ among regions and socio-economic classes (Nierenberg 2002). Most patients are prescribed psychotropic drugs, such as antidepressants. The sales of such drugs exceeded $13 billion worldwide and studies showed that the number of Americans taking them has grown to more than two-thirds in the last decade and indicated that they were not securing counseling with their drug therapy with mental health professionals. In developing nations, such drugs are not available to the general population and the mentally ill ended up in hospitals or asylums where they are abused or neglected. Few nations have proper mental health programs, even basic services for mental illness. Twenty percent of depression cases never reach or attain remission and recurrence after the first episode was said to be as high as 60%. Schizophrenia is found in women and men in equal rates and affects 24 million people worldwide. Substance abuse has already affected millions of people in the world and it is a distinctively steep problem in developing countries. Epilepsy has affected nearly 50 million people worldwide. Obsessive compulsive disorder is more common than schizophrenia and affects around 2% of the American population. Between 5 and 20% of those afflicted with eating disorders die as a result of complications because of intense fear of weight gain (Nierenberg).

Recognition and Current Response

Primary health physicians are the first line of contact with the patient and therefore have the earliest and best opportunity to recognize mental health problems and to treat them or refer the patient to specialists (Glied 1998). The sad fact is that only about half of all cases of depression are recognized by primary health practitioners and when they do, they do not treat the patients appropriately or refer them to specialists, according to studies. This failure appears to derive from the constraints of primary care practice, wherein primary care physicians are made to deal with several health problems often in a single visit. They must choose only a few to treat and even then, the time is limited for other worthwhile actions, such as counseling, control of smoking and weight control. These physicians also often do not have the adequate training for recognizing and treating mental illness. Or else, they are not very receptive to such health problems even when made aware of the patient's mental disorder. Studies revealed that a physician's attitude was highly linked with the tendency to diagnose or treat mental illness. In addition, there have been new constraints in primary care practice, which was already a time-limited, cost-conscious and managed care environment. Primary care practitioners received lower rates of diagnosis and treatment from health management organizations or HMOs than those paid by fee-for-service organizations. Short consultations are a constraint on the effectiveness and treatment of mental health problems in primary case. The administrative and gate-keeping responsibilities of managed care appeared to have limited the time primary care practitioners have been able to provide in diagnosing and treating these health problems. Patients who are able to secure longer visits are likelier to be better treated, but those who take long gaps between visits are largely unlikely to be treated. Family practitioners are likelier to treat those with mental health problems than are general practitioners and internists. Findings of other researches suggested that physician specialty and practice style were important factors in the diagnosis and treatment of mental health in the primary care level. Patients with Medicare or Medicaid insurance were more likely to obtain treatment than other patients. Being in the 18-64 age bracket, all Medicare beneficiaries qualify because of disability and are likely to suffer from some mental health problems or disorders (Glied).

Policy Initiatives

Cultural differences and the lack of manpower have hampered the service delivery by primary care organizations but policy initiatives have currently been set into place to enhance its development (Pidd 2004).

The New GMS Contract

This contains a comprehensive chronic disease management framework for a range of health conditions (Pidd 2004). Its mental health indicators provide proactive, structured care to those with severe, long-term mental health conditions or disorders and who require or agree to follow up. Frameworks have also been introduced for enhanced services, including frameworks for patients suffering from depression and alcohol abuse. These frameworks require evidence base for the need, the aim of the enhanced service, a service specification of expected practices, accreditation requirements for physicians who would provide the service, and the payments for the service. Many believed that the new contract would be a real and strong incentive to developing primary mental health care Pidd).

General Practitioners and Practitioners with Special Interest program for these practitioners contains a structured framework within which they can develop services according to their special interests (Pidd 2004). General practitioners or GPs with interest in mental health assumed that their participation would include clinical, educational, liaison, leadership and service development. Current indicators do not yet reflect the use of GPSI in mental health services, but it was viewed to be another opportunity in developing primary mental health care (Pidd).

Primary Care Graduate Mental Health Workers

The NHS Plan of the Department of Health was introduced in 2000 to manage and treat common mental health problems and would be firmly established in primary care (Pidd 2004). It promised to be a very important resource to the primary care setting, but at present, the performance has not been considerable and there have been lack of funds and local consensus, which thwart its implementation (Pidd).

Shared Care Between GP Practices and Community Health Teams

This initiative aimed at developing cooperative partnership between these teams as well as establishing systems for proactive, structured care at the practice level (Pidd 2004). Implementation has similarly been problematic. When effected, it would insure the engagement and involvement of the key staff in GP practice and local community mental health teams; a participative, facilitated process for the shared care conceptual framework; joint working groups to develop shared care agreements; and a shared understanding of priorities for improvement. Meanwhile, pilot studies conducted on personal medical services identified five factors, which could enhance successful quality improvement. These were effective collaboration with community and secondary care, effective team work within the practice, routine protocols and audits, clear objectives, and supplemental or additional financial resources. Previous and strong evidence of good organization and team work at the practice level indicated or influenced success. There have been indications of progress but, for the most part, these have been mere indicators. Nonetheless, the investment has been intensive (Pidd).

Obstacles and Issues

Little Attention Paid to Improving Primary Mental Health Care

Studies established that, in many countries, psychiatric patients had high rates of physical illness, much of which was said to be undetected (Phelan 2001). The occurrence was brought to the awareness of health professionals but there has been no evidence of response to curtail it. Instead, not only do excess illness and mortality continue to rise but also that the psychiatric outpatients now are twice as likely to die as the general population. In most industrialized countries, the trend has been to close long-stay mental hospitals and put up community mental health teams, which are designed to provide the whole range of health and social needs. Hospital admissions have lately become short and infrequent. However, many mental health practitioners have little training in physical care and the physical assessment of psychiatric patients by junior psychiatrists has been found to be below par and their monitoring generally unsatisfactory. Most patients with severe mental illness get in frequent contact with primary care services, yet this contact does not give them or insure that they receive proper physical care. Primary care has been reactive and not responsive to patients who are reluctant or unable to seek help. Doctors are also unable to assess a patient's mental state or condition during short consultations or if the patient is vague about his or condition or is suspicious about the doctor. The doctor may also be inexperienced or uncomfortable with mental health work and may resist probing deeper into the patient's symptoms while performing a physical examination. Current opinion is to establish group therapy, which can help patients with schizophrenia, for example, to stop smoking. But this initiative should be backed by strong research and address negative staff attitudes. Progress would depend on the awareness of the problem by both the mental health and primary care staff and their combined efforts at searching for and implementing imaginative and responsive solutions, which their patients would accept and consider useful (Phelan).

Fragmented Linkages of Substance Abuse Treatment with Community-Based Services

This fragmentation developed in the 80s when persons disabled with serious physical and mental disorders were considered a heavy social problem (Lee 2006). The issue grew stronger when more and more persons afflicted with substance abuse, mental illness and chronic health problems such as HIV / AIDS, began receiving outpatient treatment. This approach has been frustrating to outpatient abuse treatment providers because their clients often discontinue early, go on relapse and fall back into the habit. Researchers suggested that multiple types of treatment be provided these clients through better service linkages between outpatient substance abuse treatment entities and other service providers in order to reduce recidivism. Findings of studies and empirical evidence showed that clients receiving methadone had lower incidence of relapse when they also received ancillary services, particularly mental health services. An evaluation of a combined substance abuse and mental health case management program revealed a 31% reduction among those dually diagnosed as compared with 6% of a typical service control group. Other studies showed that those receiving services functioned better in the community than those who did not. It might take some time to link outpatient substance abuse treatment or OSAT with other health care provides as OSATs have few links with either mental health or primary care agencies and as yet are unable to work with other programs, basically managed care ones. But OSATs have been reported to making adjustments with their patterns of service linkages to the needs of substance abuse clients. Other barriers to effective linkage included inadequate insurance coverage, organizational capacity, which can be made worse by diminishing government funding during the present economic downturn (Lee).

Obstacles to Accessing Primary Mental Health Care

Managed care under the American health care system does not cover mental disease (Menaged 2003). Insurance companies look to mental health benefits as the first place to cut in an attempt to reduce rising costs. Mental health costs have been the most difficult to predict and assess and, therefore, the most risky. Every course of treatment differs from patient to patient. Other insurers sign risk agreements with providers and hospitals to administer the mental health care by their insurance subscribers in exchange for a fee. Because these administrators fix the meaning of necessity and make money out of it, private companies resort to determining what necessity was for treatment, often according to the view of the attending psychiatrist or therapist or as set by the American Psychiatric Association. Either way, insurance companies would deny the benefit. Even when mental health benefits existed, the criteria and requirements imposed by insurance companies or benefit administrators were so stringent as to render the benefits virtually inaccessible or unattainable. It has been even more difficult in inpatient cases wherein man insurance companies grant benefits only out of medical necessity, often translating to a suicide attempt. If and when the criterion for medical necessity is met, the mental disease is not necessarily cured. Hence, recurrence results in repeat episodes and succeeding hospitalizations. Victims and other clients of mental illness must eliminate obstacles before they can access needed care. These are the their own determination or choice of treatment, the right to pay privately, the exclusion of specific diseases and lack of strong link between medical or surgical care and mental health care. Treatment is required for sickness or disorder, whether visible under a microscope or invisible to eye. But the current system does not provide for the invisible and this is the current burden of mental sufferers (Menaged).