management of mental disorder

7/30/2019 Management of Mental Disorder

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MANAGEMENT OF MENTAL HEALTH

DISORDER: Primary Care SettingJoko Mulyanto

Department of Public Health &Community Medicine

Faculty of Medicine and Health Sciences

Jenderal Soedirman University



SIGNIFICANCE of MENTAL HEALTHDISORDER• High prevalence, great burden, minimal

resources.

• Global life time prevalence ranges from 12.2 – 48,6 %, while annual prevalence ranges between8.4 – 29.1%.

• Higher prevalence in low-income countries.• Most common are anxiety and depression.

• Strongly correlated with suicide

• 14 % of global burden of disease



Cont’d

• WHO estimated that in 2030, unipolardepressive disorder is second highest single

cause of global burden of disease (currently is4th).

• 35 % population in developed countries withserious mental disorder receive no treatment,

while the number in less-developed countriesrange from 75 -85 %

• Inadequate professional human resources, andallocation of financial resources.



WHY SHOULD INTEGRATE MENTALHEALTH INTO PRIMARY HEALTH CARE?• The burden of mental health disorder is great.

• Mental and physical health problems areinterwoven

• The treatment gap is significant

• Enhance access

• Respect human right• Affordable and cost effective

• Generate good outcomes



COMMON MENTAL DISORDERS INPRIMARY HEALTH CARE• Anxiety, depression, and somatisation

• Mild to moderate severity (non-psychotic)

• Significant disability

• Co-morbidity with chronic health condition

• Co-morbidity with substance abuse

• Psychosocial problems.



WHAT IS PRIMARY HEALTH CARE ?• Primary care is the provision of integrated,

accessible health care services by clinicians who are

accountable for addressing a large majority of personal health-care needs, developing a sustainedpartnership with patients, and practicing in thecontext of family and community.

• Encompassing interventions that take place in

community settings, involving families and communities (including through outreach servicessuch as those provided by community health workers) and those offered at first-level health facilities, together with mechanisms to improve

continuity of care at this level.



PRIMARY MENTAL HEALTH CARE

• Integration of mental health into primary healthcare.

• Horizontal integration

• Vertical integration

• To provide holistic and continuous care within

and between level of care• To improve the recognition and treatment of

common mental disorders at primary level.



INTEGRATION ASPECTS OF PRIMARYMENTAL HEALTH CARE• Package of care: what specific services are

provided

• Location of services : first line, formal services,community outreach

• Staffing: generalist, or professional mental

health



TYPICAL MODEL OF PRIMARY MENTALHEALTH CARE• Mental health in primary care

• Mental health at primary care

• Mental health community outreach

• Mental health care provided through othersectors



MENTAL HEALTH IN PRIMARY CARE

• Primary mental health care is part of primary health care generalist services.

• Full integration with primary level generalhealth care services with staffing by generalisthealth workers as part of their routine function.

• Staffing for mental health care is provided by

generalist staff (doctor or nurse). Staff receivetraining and supervision in mental health frommental health professionals based at a secondary or tertiary level



Cont’d

• The package of care generally includes identification,assessment (diagnosis and determination of severity andimpairment) and treatment of CMD, and prescription of

psychotropic medication .• The use of formal screening instruments, used routinely to

assist in identification• Various counseling and psychotherapeutic interventions are

increasingly being incorporated into the care package• Referral for specialist care or other services following

standard referral pathways and procedures may be arranged.• In some instances medical treatment started by a practitioner

operating at a secondary level may be continued by a primary care health worker.



MENTAL HEALTH AT PRIMARY CARE

• It is located on-site at (but not integrated with)primary level general health care services

• Staffing by specialist mental health practitioners(whether professional or auxiliary workers).

• Mental health care is provided at the site of first-

line health care (a clinic or health post)• Mental health professionals, usually nurses with

mental health training or psychiatricspecialization, but sometimes psychologists



• Identification and initial assessment of mental disorder wouldusually be undertaken by a generalist health worker

• The patient referred for confirmation of diagnosis and treatment to

the mental health practitioner.• Where patients self-identify a mental health problem, they may bepermitted to see the mental health practitioner directly

• Treatment offered by the mental health practitioner variesdepending on level of worker, professional background and mentalhealth training

• Include informal or more formal counseling or psychotherapeuticinterventions (individual, family or in a group), prescription ordispensing of psychotropic medication and case management.

• Where necessary, referrals to secondary or tertiary level care arearranged.



MENTAL HEALTH COMMUNITYOUTREACH• Mental health care is provided in community settings by

staff based in the community or operating on outreachfrom a health service

• Community/village health workers or other health workers based within the community can play animportant role in identifying, supporting and referringpeople for more specialized mental health care.

• With some mental health training, they can assist and

understand when someone needs referral to a healthpractitioner

• Workers based in the community can also visit patientsthat have defaulted or not attended the clinic/health postfor mentalhealth care as expected. This can be extremely

useful in reducing patient relapse.



MENTAL HEALTH CARE PROVIDEDTHROUGH OTHER SECTORS• Mental health care provided usually by non

healthcare organization

• For special occasion, such as natural disaster,criminal victim.

• Provide usually some aspects of primary mental

health care.• Staffing may be generalist staff (social worker,

police officer), volunteer counselor, on-site oron-call mental health professional.



HOW TO IMPROVE PRIMARY MENTALHEALTH CARE• Screening

• Assessment

• Psychotropic medication

• Counseling

• Psychotherapeutic intervention

• Organization of care



SCREENING

• Development of screening tools for commonmental disorder

• Improve rate of identification CMD by generalisthealth worker.

• Screening focus on population at “risk”

• Various tools have been developed, usually shortscreening questionnaire.



PSYCHOTROPIC MEDICATION

• To be effective, psychotropic medication must betaken at adequate dose levels and for an adequate

duration• Adequacy in number and type of psychotropic drugs

(minimum essential psychotropic drugs).

• Prescribing guideline

• Case management: follow up, treatment adherence.

• Acceptable drugs: once daily dosage, minimaladverse effect, minimal interference with everyday life, low interaction with food or drugs.



COUNSELING

• Non-medical interventions that are usually fairly limited in duration (generally not more than 6–8

sessions, but in some cases one session only) andscope (generally aimed at managing symptomsrather than more significant changes).

• It may be structured (e.g. with regard to content and

number of sessions) and at times directive.• It may be conducted by staff with limited or no

mental health training and only limited if any training in counseling specifically



INFORMAL COUNSELING

• Refers to counseling that may occur in thecontext of a health consultation.

• Lack of purpose due to variability of staff ability,consultation time, perception of biomedicalmodel.



PSYCHOEDUCATIONAL COUNSELING

• Counseling which focuses primarily on providingrelevant information (for example, regarding

symptoms, the role of related factors such asstress, coping strategies) and helping patients toapply the information in their own situation, forexample, to recognize the onset of symptoms orstress factors and tailor stress managementtechniques to deal with these.

• Evidence showed that it’s ineffective



PSYCHOTHERAPEUTIC INTERVENTION

• Psychological interventions that have an explicittheoretical base that (even in the case of brief

forms of a therapy) tend to be longer in duration(number of sessions and time period) thancounseling and that require specific training of practitioners in that model

• Cognitive-behavior therapy

• Interpersonal psychotherapy



ORGANIZATION OF CARE• Referral system: Horizontal and vertical.• Case management: assigning responsibility for

overseeing and coordinating the care of a patient toa particular member of the health care team.

• Stepped care: involving provision of low intensity interventions to a significant proportion of patients

who nevertheless derive significant benefit fromthese interventions; more intensive interventions(including referral for specialist care) are thenrestricted to patients who have more severe disorderor who fail to improve



Cont’d

• Collaborative care: is a way of organizing carethat is directed at more efficient use of resources

and more effective care for patients

management of mental disorder

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