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Focus: Mental health must be integrated into care delivery

July / August 2013 | Volume 12, Issue 4

Woman stands while nursing a baby, solemn frown on her face
Photo by Jan Sochor/Photoshare

Mental health treatment is not available in many
developing countries but it could be provided if
integrated into existing health systems, scientists
say.

By Cathy Kristiansen

There is no health without mental health, a growing body of evidence indicates, yet this aspect of care is largely neglected in the developing world. Many live their daily lives amid grinding poverty, ongoing disease outbreaks, political instability and violence - yet there are few, if any, resources available to help them deal with the mental health issues that arise. Depression, anxiety disorders, substance abuse and other crippling conditions pose an enormous burden.

To address this misery, mental health care should be integrated into existing health systems and development programs, according to a landmark series of papers published recently by PLOS Medicine. The five articles are the result of an NIH workshop organized by Fogarty's Center for Global Health Studies and co-sponsored by the National Institute of Mental Health (NIMH), National Heart, Lung and Blood Institute (NHLBI) and National Institute of Child Health and Human Development (NICHD).

"There has been a perception that mental health disorders are problems of wealthy countries and that with so many other competing health priorities in low- and middle-income countries, how could you possibly think about mental disorders?" said Dr. Pamela Y. Collins, Director of NIMH's Office for Research on Disparities and Global Mental Health. "Mental disorders are responsible for a substantial burden of illness and disability that must be addressed."

If mental, neurological and substance use disorders remain untreated, global health investments will not efficiently raise the overall health of targeted populations. Indeed, these conditions account for almost a quarter of all years lived with a disability, according to the Global Burden of Disease Study 2010. This is a huge loss in terms of individuals' well-being and productivity and extends to affecting their family, community and the economy. Mental disorders are associated with many comorbidities and related deaths, including higher HIV infection rates, cirrhosis or cancer tied to alcohol abuse and deaths from suicide.

The WHO estimates that in some low-resource countries, less than 10 percent of people with mental health problems are treated. Even in countries where mental health services are widely available, such as the U.S., only about half of potential patients seek and receive attention for their disorders.

In 2011, researchers, clinicians and advocates identified 40 Grand Challenges in Global Mental Health. The recent NIH workshop and resulting papers focus on one of those Challenges: "Redesign health systems to integrate MNS (mental, neurological and substance abuse) disorders with other chronic disease care, and create parity between mental and physical illness in investment into research, training, treatment and prevention."

The meeting focused on how mental health services can be integrated into maternal and child health care, HIV treatment and noncommunicable disease programs.

Treatment for mental disorders should be part of primary care and other global health priority programs targeted at specific health conditions, according to the papers' authors, led by NIMH's Collins. "The links between HIV and depression, cardiovascular disease and anxiety disorders, diabetes and depression - as well as other conditions - suggest that the best outcomes for these disorders require care that attends to all of them."

Emaciated man with scraggly beard and hair seated on the ground eats with his hands
Photo by Syed Ziaul Habib Roobon/Photoshare

The NIH recently convened experts to study how
mental health care could be incorporated into
existing HIV and chronic disease treatment clinics,
researchers say.

Importance of research

Research is essential to preparing the groundwork for integration of care, given that each country's sociocultural, political and health system environment is unique and poses different challenges and opportunities. Studies must be conducted to identify which interventions to adopt, how to tailor them and how to measure if they are effective and efficient. However, existing research capacity in developing countries is very limited, with less than one person per million researching mental health, according to a 2010 survey.

"The most common reasons for failure to integrate mental health care into primary or other priority health care programs are lack of adequate assessment and overly ambitious target setting," according to Dr. Vikram Patel, of the London School of Hygiene and Tropical Medicine, and his colleagues, who authored one of the Grand Challenges papers. To successfully integrate mental health into existing infrastructure will require "ongoing, iterative adaptation, hypothesis testing, performance data monitoring and improvement."

Research is required to plan screening, develop treatments for use by nonspecialists, address stigma, and create regional centers for mental health studies, education, training and practice that incorporate the needs of local people.

"It is imperative to invest in research and implementation programs so that these approaches are refined and scaled up, leading to improved outcomes," said Dr. Atif Rahman, of the University of Liverpool, and his colleagues in their paper.

Integrating care for maternal depression

Depression is the most common mental health issue globally among women of childbearing age. In addition to the economic and human costs, "children of depressed mothers are at risk for health, developmental and behavioral problems," the authors observe. These children are less likely to receive adequate levels of nutrition, immunization and breast-feeding, and are more at risk for diarrheal diseases, cognitive and social problems, and mortality.

Depression carries a heavy toll for those untreated - sometimes death but more often a higher risk for physical illness, loss of ability to work and withdrawal from family and community.

It will be very challenging for any countries to integrate mental disorders into maternal and child health (MCH) platforms, the authors noted. Many health systems are weak, with funding and staff resources scarce. Importantly, negative attitudes toward mental illnesses prevail not only in communities but also among health professionals, creating a serious hurdle to reaching and treating patients. These obstacles can and must be overcome, urged the Grand Challenges experts.

"By narrowly fixating on mortality and morbidity targets, and relegating psychosocial well-being to be a peripheral goal, the MCH community is missing an important opportunity and, in the process, depriving millions of mothers and children of their basic right to health," Rahman's team said. "This situation needs to be remedied immediately and urgently."

Researchers can help integrate mental health with chronic disease care

As developing countries confront the rapidly expanding burden of death and disability from chronic, noncommunicable diseases (NCDs), decision-makers should build mental health care into delivery solutions. "Without integration of mental health care into the NCD agenda, current NCD initiatives will be less effective and more costly," the Grand Challenges authors predict.

Nearly 80 percent of NCD deaths occur in developing countries, with the four most prevalent causes being cardiovascular and chronic respiratory conditions, diabetes and specific cancers. As the global population grows and ages, more people will suffer the burden of both mental disorders and one or more NCDs, making treatment integration essential.

For instance, patients taking antipsychotic drugs face a higher risk of related weight gain that can precipitate NCDs, such as diabetes and cardiovascular disease, and people abusing alcohol face a higher incidence of eight types of cancer. On the other hand, patients living with HIV as a lifelong, chronic disease experience more depression and suicide than the general population.

"Mental, neurological and substance use disorders frequently occur throughout the course of many NCDs and infectious diseases, increasing morbidity and mortality," noted Dr. Victoria K. Ngo, of RAND Corporation in Santa Monica, and her colleagues. "The bottom line is that the pathways leading to comorbidity of mental disorders and physical NCDs are complex and bidirectional, and care for persons with those conditions needs to be coordinated."

 

Although some research exists showing successful integration of care for mental health and NCDs, it was mostly conducted in high-income countries and the findings are not necessarily applicable to low-resource settings. A few studies in Chile, India, Uganda, Vietnam, South Africa and Pakistan have pointed to successful treatment of mental disorders in primary care settings, but the research did not examine combined mental and NCD care.

Three people in white lab coats and man in law enforcement uniform try to restrain a barefoot, disheveled man in a busy street
Photo by Bonnex Julius/Photoshare

People suffering from chronic illnesses often also have
one or more mental health condition, so it would be
more efficient to leverage existing health systems to
provide treatment for both, researchers say.

More in-country funding for research will help identify the best strategies for integrating chronic illness services with care for a broad range of mental health conditions. For instance, data are needed on the link between alcohol use disorders and severe mental illness in different cultural settings. Researchers can determine which interventions are most effective and how they can be scaled up.

The Grand Challenges paper on NCDs proposed a collaborative model of care be adopted, which would involve restructuring the roles of health care providers according to a team-based approach. Through task shifting, primary care providers and community health workers could assume some duties previously assigned to specialists, such as identifying patients who need basic mental health care, educating them about their illness, pointing out risk factors and instructing them on how to self-manage. They could also offer basic treatment, such as psychosocial therapies, as well as conduct long-term monitoring. In more complicated cases, the providers might refer patients to a specialist.

More research is needed to guide policymakers who control health spending, the authors conclude. "We must invest in designing health care systems that recognize and address the comorbidity between mental disorders and chronic physical illnesses before we are crippled by the rise in NCDs and mental health conditions."

Tackling mental disorders along with HIV

Several factors link HIV and mental disorders. Patients with HIV are twice as likely to suffer from clinical depression as uninfected people and are more likely to misuse drugs and alcohol and pursue risky behavior. Additionally, the virus undermines immune system strength and increases the likelihood of comorbidities that can impair brain function, such as tuberculosis, malaria and lymphoma. And HIV patients might face a higher risk of developing cognitive impairment over time, even if they judiciously follow antiretroviral therapy.

Ideally, both children and adults with HIV would receive treatment as early as possible after diagnosis, without waiting for elevations in viral load, to reduce the development of related cognitive problems. In many countries, this would require improvements in surveillance, diagnostic services and antiretroviral drug availability.

Context is important when integrating HIV and mental health services, including the level of available resources, the acceptability of the interventions and patients' everyday life stressors. Integrating mental health treatment into HIV primary care would provide more opportunity for early detection and effective interventions. "The evidence for the need is clear, and the evidence base for interventions suggests that it is feasible in low-resourced settings," Dr. Sylvia Kaaya, of Muhimbili University of Health and Allied Sciences, and her colleagues wrote in their paper.

Conclusion

The group concluded that there are numerous approaches to integrating mental health care within existing health services, but it is essential in all cases that policy decisions involve representatives from many different national sectors aside from only health. Ensuring research findings reach decision-makers, practitioners, managers and advocates will benefit efforts to bring innovations into practice. Policies must use evidence-based interventions that can be sustained and incorporate cultural perspectives, environmental influences and lifelong treatment programs. They should, where possible, work toward prevention.

The papers relay that ensuring mental health is part of care services in all countries will not only benefit patients with mental disorders and improve outcomes for their other illnesses such as HIV or diabetes, but will strengthen health systems through increased innovations, training, research capacity and improved infrastructure. In fact, if mental health care remains outside health systems targeting maternal, HIV and NCD care, those initiatives will be less effective and more costly.

"Health care systems in low- and middle-income countries are developing and changing rapidly, creating an opportunity to shape these systems as well as to learn how best to embed mental health services in a variety of different health system environments and sociocultural contexts," the authors noted. "It is now imperative that the mental health and NCD agendas are coordinated to leverage current political and funding commitments."

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