MINISTRY OF HEALTH

UNIVERSITY TEACHING HOSPITAL

LUSAKA COLLEGE OF NURSING AND MIDWIFERY

RNM/PHN 2020 JULY

COURSE: MENTAL HEALTH AND PSYCHIATRIC NURSING

COURSE TUTOR: MR MBULO

STUDENT: CHILESHE MUBANGA

INTAKE: RNM 2020

QUESTION: INTEGRATION OF MENTAL HEALTH INTO

DUE DATE: 08/10/2021

For too long, mental disorders have been largely overlooked as part of strengthening primary
care. This is despite the fact that mental disorders are found in all countries, both genders, at all
stages of Life, among the rich or poor and both in rural and urban settings. This is also despite
the fact that integrating mental health into primary Care facilitates person-centered and holistic
services, and as such, is Central to the values and principles of the Alma ATA declaration. With
integrated primary Care, the substantial global burden of untreated mental disorders can be
reduced, thereby improving the quality of life of hundreds of millions of patients and their
families.
DEFINITION OF TERMS

INTEGRATION:

PRIMARY HEALTH CARE:

MENTAL HEALTH:

STIGMA:

ADVOCACY:

MENTAL DISORDERS:
THE INTEGRATION OF MENTAL HEALTH SERVICES INTO PRIMARY HEALTH

The integration of mental health services into primary health care aims to increase patient
satisfaction and access to care, improved health of communities and decreased per capita costs of
care.

Despite the 1991 reforms of health system in Zambia, mental health was still given low priority.
This was evident from the fragmented manner in which mental health services were provided in
the country and the limited budget allocations with mental health services receiving 0.4 percent
of total health budget. Most mental health services provided are curative in nature and based in
tertiary health institutions. This integration has facilitated early detection and intervention for
mental health problems. This contributes to the reduction of stigma and promotion of human
rights for people with mental health problems. Integration is critical to improving and promoting
mental health of the population in Zambia and the world at large.

Primary Care physicians leads the diagnostic treatment and rehabilitation of patients with severe
mental disorders. The program has increased demands for mental health care and allowed people
with mental disorders to remain in their communities and socially integrated. The key to the
model is supported collaborative and shared Care between primary care and community services
and specialist services, which include community aged care, geriatric medicine, and old age
psychiatry. Overtime general practitioners have required less advice and support and achieved
better outcomes in terms of maintaining continuity of care.

Primary Care for mental health referrals specifically to mental health services that are integrated
into general health care level. Primary Care for mental health pertains to all diagnosable mental
disorders, as well as to mental health issues that affect the physical and mental well-being.
Services within the definition include:

Primary health workers includes medical doctors, nurses and other clinicians who provide first-
line general primary health care services.

First line interventions that are provided as an integral part or general health care and Mental
health care that is provided by primary care workers who are skilled, able and supported to
provide mental health care services.
Some of the reasons for integrating mental health care into primary health care include:

The burden of mental disorders was great mental disorders exist in a society. Hundreds of
millions of people worldwide are affected by mental disorders. They create a substantial personal
burden for the affected individuals as well their families and they produce significant economic
and social hardships that affect society as a whole. Women countries, the overall 1-year
prevalence of mental disorders range from 4% to 26%. Variability in prevalence across countries
might be due to cross cultural limitations of diagnostic tools and reporting biases. Prevalence
estimates also a likely to be influenced by stigma and discrimination.

The overall prevalence of mental disorders have been found to be almost the same for men and
women however almost all studies show a higher prevalence of depression among women than
men, as well as higher rates of anxiety and eating disorders. On the other hand, men have higher
rates of attention deficit, activity disorder and autism and substance abuse disorders. Prevalence
in children and adolescence mental health; approximately, one in 5 children suffer from a mental
disorder. Disorders regularly seen within primary Care includes attention-deficit, conduct
disorder, delirium common post-traumatic stress disorder and separation anxiety disorder.
Adolescent depression often continues unabated, into adulthood.

Prevalence of mental health in older people; the number of people aged 60 years old and older is
expected to rise to 1.9 billion in 2050. The growth rate is fastest for the oldest, who are most
likely to have chronic diseases and need help services. Their mental health is influenced by the
access to health services, education, employment, housing social services and justice and by
freedom from abuse and discrimination.

Primary Care for mental health generates good health outcomes

The majority of people with mental disorders treated in primary care have good outcomes,
particularly when linked to and network of services at secondary level of prevention and in the
community.
Primary Care for mental health is affordable and cost-effective

Primary care services for mental health are less expensive than psychiatry hospitals, for patient,
communities and governments alike. In addition patients and families avoid indirect costs
associated with chicken specialist care in distant locations.

Primary care for mental health promotes respect of human Rights and reduce the stigma 4
people with mental disorders and their families

Because primary healthcare services are not associated with any specific health condition, stigma
is reduced when seeking mental health care from primary health care providers (compared to
alone specialized services), this makes this level of care far more acceptable and therefore
accessible for many users and families. They also remove the risk of human rights violations that
can occur in psychiatric hospitals because psychiatric patients are vulnerable to stigma from
families and the community at large.

Even when stigma and discrimination are minimal, mental disorders can substantially impair
social, professional and family functioning.

It enhances access to care

Due to this integration, people can access mental health services closer to their house, thereby
keeping family together and maintaining daily activities. Just like children, people with medical
disorders may fall into depression when taken away from family and home, therefore this helps
in the treatment. It also facilitators mental health promotion in long-term monitoring and
management of affected individuals.

Mental and physical health problems are interwoven (comorbidity). Strong research evidence
has reviewed the multi-directional links between mental and physical health and illness,
thoughts, feelings and health behavior have a major impact on physical health status. Physical
health status considerably influences mental health and well-being. Mental disorders can be
precursors to physical health problems or consequences of physical health problems all the result
of interactive effects. Many people suffer from both physical and mental health problems. For
example there is evidence that depression predispose individuals to developing myocardial
infarction, and conversely myocardial infarctions increase the likelihood of depression. Similarly
panic attacks are strongly associated with asthma, people with panic disorder have a higher
prevalence of asthma and people with asthma have a higher prevalence of panic disorders. The
integration will ensure people are treated in a holistic manner, meeting the mental health needs of
people with physical disorders. Many people that usually have an accident that result in an
amputation or any other chronic condition or disease may fall into depression, therefore it is
important to help them in their mental health as mental health contributes to their physical health.

Furthermore people in the military who have recently been to a war zone area usually have post-
traumatic stress disorder (PTSD) and physical disorders, and therefore treatment has to be
conducted for both their mental and physical health. Anxious and depressed modes initiate a
cascade of adverse changes in the endocrine and immune functioning and create increased
susceptibility to a range of physical illnesses. It is known for instance that stress is related to the
development of a common cold and stress delays wound healing.

Mental health is often comorbid with physical health problems such as cancer, HIV and AIDS
diabetes and TB among others. The presence of substantial comorbidity has serious implications
for the identification and treatment and rehab of affected individuals. When primary healthcare
workers have received some mental health training, they can attend to the physical health needs
of people with mental disorders as well as the mental health needs of those suffering from
infectious and chronic diseases, this has led to better health outcomes.

Mental health problems can be somaticized

Throughout the world. People experience emotions through their bodies. Anxiety for example
may be experienced as having a knot in the stomach or sweaty palms. Depression may be
experienced as physical tiredness and slowness and even as having a heavy or painful physical
body. In addition people may comes with primary Care facility for help with the range of social
family and emotional problems but may feel that in order to be helped they must complain or
what as seen as legitimate, that is physical complaints.

Around one-third of all somatic symptoms and medically unexplained in general health care
settings. Come on medically unexplained symptoms include pain, fatigue and dizziness while
defined syndromes include irritable bowel syndrome, chronic fatigue syndrome common chronic
pelvic pain. Well medically unexplained symptoms are not necessarily caused by mental health
problems. Around 15% of patients seen in primary care settings have medically unexplained
symptoms cupboard with psychological stress and help-seeking behavior. Local expressions of
emotional distress include thinking too much, feeling things crawling through the body, sinking
heart, biting sensations over the body and heaviness sensational all over the body.

The treatment gap for mental disorders was enormous

All over the world is seen as a significant gap between the prevalence of medical disorders on
one hand and the number of people receiving treatment and care. Primary care for mental health
helps close this gap. In law and middle-income countries the treatment gap is likely to be much
greater.

Primary care services for mental health are inadequate

Despite the large number of people who attend primary care settings with mental disorders, there
recognition and treatment is generally inadequate. In many parts of the world, primary care
workers fail to detect mental disorders and for a range of reason they also failed to provide
evidence based treatment in most cases that they do identify.

Failure to detect mental disorders

The recognition of mental disorders in primary Care by primary care workers is low in moderate
at best. There is considerable variation across countries, the proportion of mental disorders
detected by treating physicians varying between 50% and 73%. Physicians are more likely to
identify somatization disorder and depression than generalized anxiety or harmful use of alcohol.
Failure to detect mental disorders may have serious consequences. Occupation and family role
dysfunction, and physical disability not explained by physical health status are common effects.
Other consequences include increased health care utilization of the patient of performance and
possibly delinquency.

Reduced chronicity and improved social integration

For both people with mental disorders and his or her household. When people are far from their
homes, it disrupts normal daily life, enjoyment and family life, it imposes more burden on
families and caregivers.
Improving human resource capacity for mental health

Integration of mental health into public health care can be an important solution to addressing
human resource

Disorders impose a substantial burden if left untreated

Many people with mental disorders ostracized from society. They descend into poverty and
become homeless as they fail to receive the treatment and care they require. In some countries
common mental disorders are considered to be magical supernatural events, caused by spirits that
take over the body. People with mental disorders are considered dangerous or contagious in the
abandoned by their families as a consequence they physically exiled from society.

Many also are discriminated against in seeking employment or education and others are
dismissed from their jobs, as such they are prevented from integrating into society and engaging
in social economic and political life.

CHALLENGES TO OVERCOME

Integration of mental health into primary health care requires a lot of careful planning and there
are likely to be several issues and challenges that will need to be addressed.

For example;

Integration of mental health into primary health care required investment in training of staff to
detect and treat mental disorders.

Within the context of training public health workers may be uncomfortable in dealing with
mental disorders and may also question their role in managing disorders. Therefore in addition to
important skills training as a means to address the overall reluctance of primary health care
workers to work with people with mental disorders.

The issue of availability of time also needs to be addressed. In many countries primary health
care workers at overburdened with work as they are expected to deliver multiple healthcare
programs. Government cannot ignore the need to increase the number of primary health care
staff if there to take on additional mental health work.
Adequate supervision of primary healthcare workers is another key issue which needs to be
addressed if the integration is to succeed. Mental health professionals should be available
regularly to primary care staff to give advice as well as guidance on management and treatment
of people with mental disorders.

Furthermore, the absence of good referral system between primary and secondary care can
severely undermine the effectiveness of mental health care at primary healthcare level.

Finally governments must pay attention to key human resource management issues in primary
healthcare- adequate working conditions, payments, resources and support to carry out
demanding work.

PRINCIPLES OF INTEGRATING MENTAL HEALTH INTO PRIMARY

Advocacy

Is required to shift attitude and behavior, advocacy is an important aspect of mental health
integration. Information can be used in deliberate and strategic ways to influence others to create
change. That’s what health education is all about.

Time and effort are required to sensitize national and political leadership, health authorities and
management and primary healthcare workers about importance of integration of mental health
into primary healthcare. Estimates of the prevalence of mental disorders, the burden they impose
if left untreated, the human rights violations that often occur in psychiatric hospitals and their
existence of effective primary care based treatments are often important arguments.

Policy and plans need to incorporate primary care for mental health. Commitment from the
government to integrate mental health care and a formal policy and legislation that concretizes
Thai commitment, are fundamental to success. Integration can be facilitated not only by mental
health policy, but also by general health policy that emphasize mental health services at primary
care level. National directives can be fundamental in encouraging and shaping improvements.
Conversely, local identification of needs can start a process that flourishes and prospers with
subsequent government facilitation.
Adequate training of primary care workers is required; pre-service and/or in-service training of
primary health care workers in mental issues is essential for mental health integration. However,
healthcare workers must also practice skills and receive specialist supervision overtime.
Collaboration or shared care models, in which joint consultation and interventions are held
between primary care workers and mental health specialists, are an especially promising way of
providing ongoing treatment and support.

Primary care tasks must be limited and doable

Typically primary healthcare workers function best when their mental tasks are limited and
doable. Decisions about specific areas of responsibility must be taken after consultation with
different stakeholders in the community, assessment of available human and financial resources
and consideration of the strengths and weaknesses of current health systems for addressing
mental health. Functions of the primary care workers may be expanded as practitioners gain
skills and confidence.

Specialist mental health professionals and facilities

Must be available to support primary Care. The integration of mental health systems into primary
Care is essential, but must be accompanied by complementary services. Particularly secondary
care component to which primary care workers can turn to for referrals, support and supervision.
This support can come from community mental health centers, secondary level hospitals or
skilled practitioners working specifically within primary care systems. Specialist may range from
psychiatric nurses to psychiatrists.

Patients must have access to essential psychotropic medication in primary care. Access to
psychotropic medication is essential for the successful integration of mental health into primary
healthcare. This requires countries to directly distribute psychotropic medications to primary care
facilities rather than their psychiatric hospitals. Countries also need to review and update a
legislation and regulations to allow primary care workers to prescribe and dispense psychotropic
medications, particularly where mental health specialist and physicians are scarce.
Integration is a process, not an event

Even when a policy erupts, integration takes time and typically involves a series of
developments. Meetings with a range of concerned parties are essential and in some cases,
considerable skepticism or resistance must be overcome.

After the idea of integration has gained general acceptance karma there is too much work to be
done. After the idea of integration has gained general acceptance, there is too much work to be
done. Help workers need training and additional staff might need to be employed. Before any of
this can occur, budget typically will require agreement and allocation.

A mental health system coordinator is crucial

Integration of mental health into primary health care can it be incremental and opportunistic,
reversing or changing directions and unexpected problems can sometimes to return the programs
outcome or even it’s survival. Mental health coordinators are crucial in staring programs around
these challenges and driving forward the integration process.

Collaboration

With other government health sectors, non-governmental organizations, village and community
health workers and volunteers is required. And government sectors outside health can work
effectively with primary Care to help patients with mental disorders assess education, social and
employment initiatives is required for their recovery and integration into the community. Non-
governmental organizations, villages and community health workers and volunteers often play an
important role in supporting primary Care for mental health. Villages and community health
workers can be tapped to identify and refer people with mental disorders to primary care
facilities. Community-based non-governmental organizations can help patients become more
functional and decrease the need for hospitalization.

Financial and human resources are needed

Other primary Care for mental health is cost-effective, financial resources are required to
establish and maintain a service, Training costs needs to be covered and additional primary and
community health workers might be needed. Mental health specialists who provide support and
supervision must also be employed.
SUMMARY

Mental disorders affect hundreds of millions of people and if left untreated can create an
enormous toil of suffering, disability and economic loss. Integration of mental health services
into primary Care is the most viable way of closing the treatment gap and insuring that people
get the mental health care they need. It is therefore affordable and investments can bring
important benefits. Furthermore, integration is not successful when mental health is incorporated
into health policy and legislative frameworks and supported by senior leadership, adequate
resources and ongoing governance. To be fully effective and efficient, primary Care for mental
health must be fully coordinated with the network of services at different levels of care and
complemented by broader health systems development. Mental health is Central to the values
and principles of the Alma ATA declaration, holistic care will never be achieved until mental
health is integrated into primary Care.
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