An international perspective on youth mental health: the role of primary health care and collaborative care models.

TLDR: The World Health Organization urges governments in both high-income and low- and middle-income countries to scale up services for mental health by making available an optimal mix of services comprised of informal community care, primary care services, community mental health services and specialized inpatient facilities.

Abstract: Mental health problems make a significant contribution to morbidity and mortality in youth worldwide. Suicide is the third highest cause of death in young people and neuropsychiatric disorders, including specifically depression, schizophrenia and alcohol abuse, are the leading cause of disability in young people in all regions (Gore, 2011; Patton et al., 2009; World Health Organization, 2004). If poor mental health during adolescence and early adulthood goes unrecognized, it increases their vulnerability to poor psychological functioning in the immediate and long term, and leads to lost economic productivity and increased costs to society. Yet, in many countries only a small minority of young people with mental health problems are able to access appropriate resources for recognition, support, care and treatment (Morris et al., 2011). Health services for adolescents and youth who are at risk but who do not yet exhibit clinical symptoms are even more inadequate (Knitzer, 2000). The World Health Organization (WHO) urges governments in both high-income and low- and middle-income countries to scale up services for mental health by making available an optimal mix of services comprised of informal community care, primary care services, community mental health services and specialized inpatient facilities (WHO, 2001; 2012). The WHO also emphasizes the critical importance of integrating mental health into general health facilities, moving away from historical models of vertical mental health systems largely relying on psychiatric hospital-based approaches to treatment, which are often ineffective and fraught with human rights violations. It encourages provision of youth mental health care at the primary health care level, close to communities and with young peoples’ active engagement in monitoring the quality of care (WHO and World Organization of Family Doctors, 2008; WHO, 2005). There are many potential advantages of including youth mental health in health care services at the primary health care level. Primary care mental health services facilitate the early identification and treatment of mental disorders and have the potential to dramatically increase and equalize access to care. Primary health care professionals are best placed to adopt holistic and ecological approaches to care which acknowledge the frequent coexistence and close relationship between physical and mental ill health, and ensure the engagement and empowerment of available resources within families, schools and communities. Health workers can establish trusting and long-term relationships with youth and prevent mental health problems by promoting healthy lifestyles, providing anticipatory guidance and offering timely interventions for common behavioural, emotional and social problems. Primary care workers have a knowledge of community resources and health, social and education services, and can better respond to the specific needs of local communities (Kramer & Garralda, 2000). From an economic perspective, primary care services are usually the most affordable option for both users and governments. Primary-care worker-generated referrals are usually more appropriate and better directed, thus minimizing waste of scare financial and human resources. Youth with mental health concerns avoid the indirect costs associated with seeking specialist care in distant locations. Furthermore, mental health services delivered close to communities minimize stigma and discrimination, and foster respect of human rights (WHO and World Organization of Family Doctors, 2008). Research on scaling up mental health services has identified a number of common barriers to mainstreaming youth mental health care into primary care services. They include inadequate skills and competences of primary health care providers to perform mental health promotion, prevention and care tasks, unclear job tasks, and excessive workload (Eaton et al., 2011). Fragmentation of services among diverse levels of the health care system and among different community-based services across sectors (e.g. social, educational, occupational, juvenile justice and rehabilitation services) is another major challenge reported by health professionals in primary care services. As a consequence, youth at risk or with mental disorders encounter difficulties in finding appropriate comprehensive responses to their complex and multi-layered needs. Finally, a low utilization of available services by youth compounds the problem (Osher, 2002). Making available clinical classifications and protocols for the management of mental disorders to primary care providers is not sufficient to overcome the above mentioned barriers or to promote the effective integration of mental health care services and to scale up services for mental health in primary care settings. Increasing evidence from health system research documents that deep transformational changes at the policy level, in health systems organization and management, and training and management of human resources is required (Jenkins & Strathdee, 2000; Kakuma et al., 2011). Among other health system organizational innovations, the adoption of collaborative practices is being proposed as a key ingredient of community-based health care system responses. In collaborative models, general practitioners retain primary responsibility of care but professionals with complementary skills (traditionally mental health professionals) work as part of a package of care, liaising with both patient and health worker to increase the overall effectiveness of care. Collaborative approaches are based on a strong partnership between first line health workers and other professionals with diverse expertise and mandates, who work together to meet users’ needs. They imply task shifting and task sharing among a multidisciplinary team of professionals. Collaborative approaches increase the feasibility of assessment and management of mental disorders by busy health workers in community-based settings, while also promoting provision of good quality and comprehensive mental health care. The adoption of collaborative care models may result in increased service uptake by adolescents and youth, as they tend to prefer receiving care by general health practitioners and in non-specialized (and hence less stigmatizing) health settings (Kramer & Garralda, 2000; Bower, 2002; Bower, Garralda, Kramer, Harrington, & Sibbald, 2001). The WHO recently launched a program—the Mental Health Gap Action Program (mhGAP)—aiming specifically at scaling up mental health services by integrating mental health into primary health care. It adopts a life-cycle approach and targets adolescents and youth, among other age groups (WHO, 2008). The program provides technical guidance for mainstreaming mental health in primary care settings, simple evidence-base guidelines for assessment and management of mental disorders by non-specialist health care providers, and training materials for clinical staff at various levels (WHO, 2010). The implementation of mhGAP at the primary health care level implies the establishment of structured collaboration mechanisms with mental health specialists, schools, social and rehabilitation services. Management tasks of primary care workers include liaising with social services and community resources, providing advice to teachers, and providing skills training to parents. Policy makers, planners, clinical staff and service users are actively engaged in the adaptation of the proposed model to the local context and health system organization. An important preliminary step in the adaptation process is the analysis of available local needs and resources (i.e. community needs, organization of services, available human resources and skills mix), followed by the redefinition of tasks, a planning of appropriate capacity building targeting different cadres and according to specific competence gaps and roles (including the provision of supportive supervision and consultations), and the establishment of a mechanism for collaborative practice. The program is currently being pilot tested in several countries. The evaluation of these demonstration projects will contribute to increase the evidence on outcomes of youth mental health care provision at primary health care settings through collaborative care models.