This is the fifth part of an IH Blog series, Global Mental Health: Burden, Initiatives and Special Topics.
In the context of a pandemic, access to and the quality of mental health care is paramount. Effective and feasible delivery models for mental health care service provision are critical for meeting growing demands for care. Many new and innovative models have been proposed and integrated approaches have been identified as potentially effective strategies to address this growing need. The goal of integrated mental health care is to enhance accessible, affordable, cost-effective mental health services for individuals. There are a range of different integrated care models including collaborative care, hub-based systems, and patient-centered medical homes. Collaborative care, for example, is an integrated care program that combines behavioral health care management and consultations with mental health specialists in the primary care setting.
Mental health care provision in the context of primary care settings is important because primary care is the first point of contact for patients in the healthcare system. The Declaration of Alma-Ata, adopted at the 1978 International Conference on Primary Health Care organized by UNICEF and WHO, identified primary health care as a central function of health systems and the key to attaining the goal of ‘Health for All.’ Forty years later, at the Global Conference on Primary Health Care, primary care was re-emphasized as the most effective way to sustainably solve today’s health challenges, partly through the provision of integrated services. The promotion, maintenance and improvement of mental health is explicitly included in the 2018 Declaration as a service that primary health care should provide to patients.
Mental illness is frequently comorbid with a long list of chronic illnesses and disorders. Depression is common among people who have cancer, coronary heart disease, diabetes, multiple sclerosis, HIV/AIDS, and rheumatoid arthritis, among other chronic illnesses. Some disorders increase the risk of depression. At the early stages of Parkinson’s disease dopamine decreases which can cause depression. Chronic stress, whether it be illness-related or social stress, can trigger anxiety and depression. Researchers have found high levels of the stress hormone, cortisol, to disrupt neuroplasticity in brain structures that are functionally abnormal in depression, such as the hippocampus. Medication used to treat certain chronic disorders can lead to depressive symptoms. Nifedipine, used in the treatment of cardiovascular conditions, has been linked with the induction of depression. Even drugs used to treat and prevent asthma have been found to have psychiatric side effects. Bronchodilators mimic adrenaline and trigger the body’s sympathetic “fight or flight” nervous system response. This response causes one to feel anxious and panicky. Montelukast is another asthma medication that has neuropsychiatric side-effects in children and has recently elicited the FDA to require a stronger box warning of the side-effect.
Conversely, adults with serious mental illnesses are at greater risk for chronic physical illnesses and other medical conditions, such as stroke and cardiovascular disease, than the general population. One explanation for this association is that individuals with mental illness can have a harder time caring for themselves, seeking care, eating well, exercising and taking medication as prescribed. Scientists have found that depression increases inflammation, reduces heart rate variability, and disturbs the metabolic system.
Ethiopia, India, Nepal, Nigeria, South Africa and Uganda have strengthened integrated mental health care through the World Health Organization’s mhGAP program. Through the mhGAP program, primary care providers are trained to identify and manage mental disorders, prescribe psychotropic medication, and provide evidence-based psychosocial interventions. For integrated mental health care to fully flourish, change needs to come from within the medical sector, as well as outside of it, in the policy sector. The Netherlands, since the early 2000s, has worked to integrate mental health care into a number of health care settings, including hospitals and community health centers. They also introduced an innovative bundled payment system in 2007 to promote and incentivize integrated care.
There are many challenges inherent in implementing integrated care models. Countries face resource constraints including workforce shortages. Primary care providers can be trained to provide mental health care, but they must be supported by secondary mental health professionals who are the experts in their field. Finally, to ensure optimal success and sustainability, countries must enact legislation that fosters the development of infrastructure that supports integrated mental health care.
About the Authors:
Elena Schatell MPH (c) MMS (c)
Elena Schatell is a current student at Arcadia University enrolled in the Dual Master of Public Health/Master of Medical Science in Physician Assistant Program. She aims to promote public health in underserved communities as a future physician assistant. Her current public health interests include access to mental health services, stigma surrounding mental illness, and the relationship between faith and mental health. She has interned at the National Alliance for Mental Illness (NAMI) national office in Arlington, Virginia, working closely with the Advocacy and Public Policy team on conducting research on service barriers and state mental health policy. During her time at NAMI, she also authored articles for the Advocate magazine and blog.
Dr. Heather F. McClintock PhD MSPH MSW
Dr. McClintock is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life Study and Integrating Management for Depression and Type 2 Diabetes Mellitus Study.