A Integracao de A Integracao de Saude Mental na Saude Mental na Atencao Basica:Atencao Basica:

Defining the Roles and Defining the Roles and Challenges in the Family Health Challenges in the Family Health

ProgramProgramAnh Tuyet VuongAnh Tuyet Vuong

FIOCRUZFIOCRUZ

CSEGSF/ENSPCSEGSF/ENSP

Georgetown UniversityGeorgetown University

School of Nursing and Health StudiesSchool of Nursing and Health Studies

December 5, 2008December 5, 2008

IntroductionIntroduction

Mental illness accounts for 7 out of Mental illness accounts for 7 out of top 10 causes of DALYstop 10 causes of DALYs

Large treatment gaps: Large treatment gaps: 55% of patients depression are not 55% of patients depression are not

treated treated 77% of anxiety disorders are not 77% of anxiety disorders are not

detecteddetected Impacts health, social relationships, Impacts health, social relationships,

family structure and work/economicsfamily structure and work/economics

Importance of the Importance of the Integration of Mental Integration of Mental

Health in Primary CareHealth in Primary Care Reduces stigma- treated alongside primary care Reduces stigma- treated alongside primary care

patientspatients Improves accessibility Improves accessibility More Humane in comparison to mental asylumsMore Humane in comparison to mental asylums

Less disruptions, people can remain with families and Less disruptions, people can remain with families and communitiescommunities

Cost-effective and produces good health outcomesCost-effective and produces good health outcomes Cheaper to treat cases at primary care level than secondary & Cheaper to treat cases at primary care level than secondary &

tertiarytertiary Mentally ill use more health care resourcesMentally ill use more health care resources Shared ResourcesShared Resources Coordination of activities between PHC and MH professionals Coordination of activities between PHC and MH professionals

reduces burden of tasksreduces burden of tasks

Mental Health and Physical Mental Health and Physical HealthHealth

Mental illness affect and are affected Mental illness affect and are affected by somatic health conditionsby somatic health conditions

Mentally ill die an average of 20 years Mentally ill die an average of 20 years earlier than the average personearlier than the average person

Integrating MH and PHC improves Integrating MH and PHC improves treatment of health problems for treatment of health problems for mentally ill as well as improves mentally ill as well as improves treatment of psychological concerns treatment of psychological concerns for the physically illfor the physically ill

High Prevalence of Mental Disorders

Link between Mental and Physical Health

Large Treatment Gap

Enhanced

Access

Respects Human Rights

Cost-Effectiven

ess

Reduction of

Stigma

Good Health

Outcomes

ObjetivosObjetivos

Define and identify roles, responsibilities, Define and identify roles, responsibilities, strengths and weaknesses of health strengths and weaknesses of health professionals and mental heatlh professionals and mental heatlh professionalsprofessionals

Understand perceptions, knowledge and Understand perceptions, knowledge and approaches to mental health of professionalsapproaches to mental health of professionals

Examine barriers and facilitating factors to Examine barriers and facilitating factors to detection, diagnosis, treatment and care of detection, diagnosis, treatment and care of the mentally ill within the Manguinhos the mentally ill within the Manguinhos communitycommunity

MethologiaMethologia

11 semi-structured interviews were conducted 11 semi-structured interviews were conducted regarding perceptions of mental health within regarding perceptions of mental health within the community, challenges and facilitating the community, challenges and facilitating factorsfactors 6 ACS6 ACS 2 mental health professionals2 mental health professionals 1 technica de enfermagem1 technica de enfermagem 2 enfermeros2 enfermeros

Diario de Campo was used to record generaly Diario de Campo was used to record generaly observations from domestic visits, patient observations from domestic visits, patient consulations and family health team meetings.consulations and family health team meetings.

ResultadosResultados

Contexto da ComunidadeContexto da Comunidade High rates of poverty, cramped living High rates of poverty, cramped living

conditions, unemployment and prevalent conditions, unemployment and prevalent violenceviolence

Common Mental Illnesses: Depression, Common Mental Illnesses: Depression, anxiety, psychosomatic illnesses and mood anxiety, psychosomatic illnesses and mood disordersdisorders

Low stigma against mentally illness Low stigma against mentally illness because of violence and other concerns because of violence and other concerns Could facilitate treatment or it could desensitize Could facilitate treatment or it could desensitize

people and hinder care-seeking behavior people and hinder care-seeking behavior Knowledge about mental health concepts Knowledge about mental health concepts

and mental illness in the community is and mental illness in the community is limited limited

Roles of Health Professions Roles of Health Professions in Mental Health Cases in Mental Health Cases

Mental Health

Professional

Nurse

Doctor

Secondary & Tertiary

care

Nurse Technician

Self or Family

seeks care

ACS Community

Referral

Two Perspectives Two Perspectives on the Integration on the Integration of Mental Health of Mental Health

into ESFinto ESF

Inclusive PerspectiveInclusive PerspectiveRegardless of training and background, everybody Regardless of training and background, everybody

can play a role in the care of the mentally illnesscan play a role in the care of the mentally illness

““The role of the other health professionals should The role of the other health professionals should not just simply be forwarding cases of mental not just simply be forwarding cases of mental illness to the psychologist or the psychiatrist and illness to the psychologist or the psychiatrist and leaving the patient with the mental health leaving the patient with the mental health profession… The idea is to…change this profession… The idea is to…change this mentality to value the fact that family health mentality to value the fact that family health teams are closer to the community. They know teams are closer to the community. They know [the patients] better because of their day-to-day [the patients] better because of their day-to-day home visits. They know the stories that they home visits. They know the stories that they patients tell to the ACS’s. They are valuable patients tell to the ACS’s. They are valuable resource.” (Psychologist)resource.” (Psychologist)

Advantages of ESFAdvantages of ESF

Closer to the familyCloser to the family Trust of the residentsTrust of the residents A deeper understanding of community A deeper understanding of community

dynamics and patient’s historydynamics and patient’s history Live within the communityLive within the community

More access to mentally ill who are More access to mentally ill who are isolated isolated

Knows the community resources and rules Knows the community resources and rules

Exclusive PerspectiveExclusive Perspective

Psychiatry is a very specialized fieldPsychiatry is a very specialized field Handling cases of mental illness Handling cases of mental illness

requires specialized training and requires specialized training and education education

Without appropriate trainingWithout appropriate training Frustrations and burn-out from not Frustrations and burn-out from not

being able to handle casesbeing able to handle cases ineffectively, could possibly harm ineffectively, could possibly harm

patientspatients

““I encounter mental health situations [ in my I encounter mental health situations [ in my work]. But it is difficult for me to identify the work]. But it is difficult for me to identify the situation. The ACS only has a one month situation. The ACS only has a one month training class, so we are not sufficiently training class, so we are not sufficiently trained to analyze situations like mental trained to analyze situations like mental health. So we have learn [on the job] by health. So we have learn [on the job] by looking. When you are just looking you can’t looking. When you are just looking you can’t really detect certain cases like mental health really detect certain cases like mental health cases... Our training is really rapid and it was cases... Our training is really rapid and it was over things like hypertension diabetes and the over things like hypertension diabetes and the history and policy of the family health history and policy of the family health program” (ACS, Equipe 2)program” (ACS, Equipe 2)

““We have things that we cannot We have things that we cannot achieve and sometimes, we think achieve and sometimes, we think that we should just leave it alone that we should just leave it alone and not bother with it. Because and not bother with it. Because sometimes, it is a lot easier to sometimes, it is a lot easier to abandon the work than to put out abandon the work than to put out the effort and try…There are many the effort and try…There are many people out there who already have people out there who already have lost hope” lost hope”

-ACS, Equipe 2-ACS, Equipe 2

Balancing the Two ViewsBalancing the Two Views

Inclusion of other health professionals of the Inclusion of other health professionals of the ESF leads to more holistic careESF leads to more holistic care

Clearly defining roles and responsibilities, Clearly defining roles and responsibilities, supported by appropriate training ensures supported by appropriate training ensures quality cared delivered by qualified quality cared delivered by qualified professionalsprofessionals

““The mental health team is starting to try to The mental health team is starting to try to work with the family health teams and give work with the family health teams and give them support and our time and expertise. We them support and our time and expertise. We are trying to work with the family health teams are trying to work with the family health teams at the primary level, while maintaining the at the primary level, while maintaining the secondary levels also. After a while, maybe we secondary levels also. After a while, maybe we can strike a better balance.” (Psychologist)can strike a better balance.” (Psychologist)

Conditions for the Conditions for the Successful integration of Successful integration of

MH into PHCMH into PHC PHC staff must have knowledge, skills and PHC staff must have knowledge, skills and

motivation to treat and manage mentally illmotivation to treat and manage mentally ill Sufficient MH professionalsSufficient MH professionals Psychotropic drugs must be availablePsychotropic drugs must be available Wide range of services that responds to Wide range of services that responds to

individuals and populationsindividuals and populations Well-defined roles and responsibilitiesWell-defined roles and responsibilities Strong links Strong links

between MH and PHC professionals, recording between MH and PHC professionals, recording systems for monitoring and evaluationsystems for monitoring and evaluation

Between primary, secondary and tertiaryBetween primary, secondary and tertiary With communityWith community

RecommendationsRecommendations

Psychological support for health Psychological support for health professionals, especially for ACSprofessionals, especially for ACS

Integration of mental health activities Integration of mental health activities into pre-existing health promotion into pre-existing health promotion programs for specialized populationsprograms for specialized populations

Improvement of the links and Improvement of the links and interactions between MH professionals interactions between MH professionals and ESF, especially ACSand ESF, especially ACS

Increased training for ACSs and ESF in Increased training for ACSs and ESF in mental healthmental health

ConclusionsConclusions

The health center has an excellent model The health center has an excellent model for the integration of mental health into for the integration of mental health into primary careprimary care

However, integration is processHowever, integration is process Detected cases are generally well Detected cases are generally well

handled, however there is still a handled, however there is still a treatment gaptreatment gap

Improving connections between ESF and Improving connections between ESF and SM professionals as well as improved SM professionals as well as improved training in SMtraining in SM

Who is more crazy?Who is more crazy?

““Individual isolated cases of Individual isolated cases of foolishness and personal insanity are foolishness and personal insanity are

not as terrible as the widespread, not as terrible as the widespread, organized, widespread social organized, widespread social

insanity of our world.”insanity of our world.”

-Leo Tolstoy -Leo Tolstoy

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