Creating life lines – integrating mental health services into primary care

WHO/Aigerim Tumenbay

People diagnosed with chronic conditions suffer from high rates of depression. Depression, for example, occurs in up to 20% of patients with diabetes and coronary heart disease – 2 of the most common conditions diagnosed, treated and managed in primary care. Despite being associated with significant disability and an excess rate of mortality, depression comorbidities often remain undiagnosed.

Furthermore, despite the relatively high prevalence of depression in the population at large, including the elderly and youth, its diagnosis and treatment remain a challenge due to the fact that patients do not always present to their primary care doctor with depression as their primary complaint. This, in turn, can lead to inadequate treatment and poor patient care.

Dr Paul Giesen, a primary care physician in the Netherlands, says, “I have seen many of my patients not recognize they have depression. Rather they present with somatic complaints, alcohol or drug abuse issues or complain about problems at home and at work.”

As the first point of care in most countries, primary care doctors and nurses are well positioned to prevent, diagnose, manage and care for patients struggling with depression. They can achieve this in ways that are tailored to the daily realities of the patient’s life, family and community, and can act as the main convenors of the patient’s other health providers. This can ensure timely, accessible and person-centred care as well as reduced stigma.

Training to screen, prevent, treat and prescribe

While screening for depression is one of the first ways that primary care doctors and nurses can help, it is important that they are also equipped with resources to follow up on the results of these screenings; primary care teams require adequate training to screen and prevent, but also to treat and prescribe.

Essential resources include evidence-based clinical guidelines that take into consideration the roles of primary and specialized care, such as the WHO Mental Health Gap Action Programme (mhGAP) intervention guide. These tools help guide and delegate decision-making among providers across the continuum of care and the patient’s life-course. They also advise primary care providers on how to manage and monitor their patients over time to ensure quality of care.

Collaboration across primary and specialized care, the use of health care plans, the introduction of new professional roles such as clinical educators and case managers, and the promotion of self-management have also been shown to be of key importance in the effective management of depression. When needed, for example, primary care teams can engage other health providers such as physiotherapists, psychiatrists, psychologists, social workers and other mental health specialists to contribute their expertise and reinforce or adjust care plans.

Dr Giesen says, “As a general practitioner, I am supported by national guidelines that help me recognize depression and differentiate it from other disorders, suicidal ideation, psychosis and bipolar disorder. With guidelines addressing the role of primary care and my training, I am able to take a more proactive approach in supporting my patients with self-help tools, providing psychological counseling, intensive psychotherapy and prescribing antidepressants more appropriately. I prepare action plans and care plans together with the patient and my primary care team so that there is a shared problem definition and we can better support patients to assume personal responsibility in their recovery process.”

He continues, “Next door to my clinic I have psychologists that I can reach out to for help in getting longer term support for complicated and chronic cases of depression but most problems we treat in our primary care team. I only send about 20% of our patients who have severe and present high risk to hospital for psychiatric treatment.”

Equipping primary health care facilities with the means to diagnose and treat depression has clear benefits: better health for the patient, reduced burnout for practitioners and diminished costs.

WHO/Europe, through the WHO European Centre for Primary Health Care in Almaty, Kazakhstan, provides technical support to countries for strengthening the delivery of health services based on a primary-health-care approach. The Centre’s work is based on the European Framework for Action on Integrated Health Services Delivery, which was adopted by WHO Member States in 2016.