Treatment of common mental disorders in primary care in low- and middle-income countries

Common mental disorders are responsible for up to 10% of the total global disease burden. The growing evidence base for the efficacy and cost-effectiveness of treatments for these disorders raises the possibility of delivering huge health and economic benefits. However, delivering these treatments in resource-constrained settings is challenging. At least one-third of all patients seen in primary care in low- and middle-income countries present with common mental disorders. The majority are not recognised or are ineffectively treated. To address this problem, WHO advocates integrating mental health in primary care. However, the limited evidence base has impeded efforts to develop such services.     

Beyond symptoms: defining primary care mental health clinical assessment priorities, content and process

The assessment of undifferentiated psychological distress is a daily aspect of primary care practice. Primary care practitioners' underlying values influence the priorities, process and content of assessment. Currently there is a lack of definition of these values in primary care clinical mental health assessment. This paper presents the case for adopting the philosophical values and principles of holistic transdisciplinary generalism to influence practice worldwide. Furthermore, it raises awareness of current constraints on practice, including an overreliance on the psychiatric paradigm of care and resulting criteria-based diagnoses. Finally, the paper seeks to promote discussion among primary care practitioners and researchers globally about how to define primary care clinical mental health assessment priorities, process and content.     

A collaborative care program for management of common mental disorders among diabetic patients in a primary healthcare setting

Aims

Type 2 diabetes mellitus (T2DM) is a chronic condition with high and increasing prevalence. Psychiatric disorders are very common among these patients. We aimed to assess the effect of a collaborative care program for management of common mental disorders among T2DM patients on their metabolic outcomes.

Subjects and methods

In this before-after study, a group of T2DM patients was enrolled from nine chronic care centers of a primary healthcare service. A trained team managed both the psychiatric and metabolic conditions according to evidence-based guidelines. The primary care team was in collaborative contact with a specialized service at a Community Mental Health Center. Patients’ glycemic measures, lipid profile, and weight were measured 3 months after the psychiatric intervention.

Results

Among 2757 diabetic patients visited, 536 (19.44 %) were diagnosed as having a common mental disorder. Mean age of included patients (435) was 56.5?±?9.74. Major depressive disorder and generalized anxiety disorder were the most common mental disorders with a frequency of 219 (50.3 %) and 197 (46.7 %), respectively. There was no statistically significant improvement in glycemic and metabolic control after the psychiatric intervention; however, control of blood pressure was improved. Moreover, significant improvements were observed in average glycosylated hemoglobin (HbA1c) (p?<?0.001) and fasting plasma glucose (FPG) (p?<?0.01) in patients with previously poor glycemic control.

Conclusion

Although management of psychiatric conditions in a collaborative care program yielded no significant effect on metabolic outcomes and glycemic control in the total sample, patients with poor glycemic control experienced significant improvement in FPG and HbA_1c levels.

     

Identified mental disorders in older adults in primary care: A cross-sectional database study

Introduction: Identifying and managing mental disorders among older adults is an important challenge for primary care in Europe. Electronic medical records (EMRs) offer considerable potential in this regard, although there is a paucity of data on their use for this purpose.

Objectives: To examine the prevalence/treatment of identified mental disorders among older adults (over 55 years) by using data derived from EMRs in general practice.

Methods: We utilized data from a cross-sectional study of mental disorders in primary care, which identified patients with mental disorders based on diagnostic coding and prescribed medicines. We collected anonymized data from 35 practices nationally from June 2014 to March 2015, and secondary analysis of this dataset examined the prevalence of mental disorders in adults aged over 55 years.

Results: 74,261 patients aged over 55 years were identified, of whom 14,143 had a mental health disorder (prevalence rate of 19.1%). There was considerable variation between practices (range: 3.7–38.9%), with a median prevalence of 23.1%. Prevalence increased with age, from 14.8% at 55–59 years to 28.9% at 80–84 years. Most common disorders were depression (17.1%), panic/anxiety (11.3%), cognitive (5.6%), alcohol (3.8%) and substance use (3.8%).

Conclusions: Examining mental disorders among older adults using data derived from EMRs is feasible. Mental disorders are common among older adults attending primary care and this study demonstrates the utility of electronic medical records in epidemiological studies of large populations in primary care.     

Adolescents with co-occurring mental health and substance use disorders in primary care

Co-occurring mental and substance use disorders (COD) among children and adolescents present special challenges for family members and primary care clinicians. A broad understanding of prevalence rates, etiology, risk and protective factors, and intervention strategies is important in promoting evidence-based practices. The authors present a synopsis of important issues in this area and provide support for integrating behavioral health into primary care practice.     

Management of mental disorders in rural primary care: a proposal for integrated psychosocial services

Mental health facilities and specialized providers are particularly lacking in rural areas. Even when these are available, poverty, negative attitudes toward mental health treatments, and traditional rural values of privacy and autonomy often result in low utilization rates. Consequently, most mental health care in rural America is provided by primary care physicians who are also faced with competing demands, including tensions among limited time and resources, the multiple and complex needs of patients, and economic forces determining reimbursements. We propose that in the best interest of physicians and their patients, fully integrated psychosocial services in rural primary care settings would reduce the burden of time-consuming mental health care, conform to patient preference for immediate on-site care, reduce nonproductive medical care use, and eliminate duplication of effort by physicians and mental health professionals. The treatment model we propose would provide multiple arenas for psychosocial intervention - with the individual, the family, and the community - based on the patient's self-identified needs. The integration of psychosocial services within primary rural care is readily available, economically feasible, and urgently needed, but physicians must take the lead to implement this collaborative treatment partnership.     

Prevalence and correlates of mental disorders among Native American women in primary care

OBJECTIVES: We examined the lifetime and the past-year prevalence and correlates of common mental disorders among American Indian and Alaska Native women who presented for primary care. METHODS: We screened 489 consecutively presenting female primary care patients aged 18 through 45 years with the General Health Questionnaire, 12-item version. A subsample (n = 234) completed the Composite International Diagnostic Interview. We examined associations between psychiatric disorders and sociodemographic variables, boarding school attendance, and psychopathology in the family of origin. RESULTS: The study participants had high rates of alcohol use disorders, anxiety disorders, and anxiety/depression comorbidity compared with other samples of non-American Indian/Alaska Native women in primary care settings. CONCLUSIONS: There is a need for culturally appropriate mental health treatments and preventive services.     

Diagnostic reliability in mental disorders of the International Classification of Diseases in primary care

INTRODUCTION: The objective is to evaluate the test version of Chapter V - "Mental and Behavioral Disorders reliability", of the 10th revision of the International Classification of Diseases, Version for Primary Care (ICD -10 PC), prepared by the Division of Mental Health of the World Health Organization (WHO). METHODS: During September and October of 1994, Community General Physicians (CGP) from the Health and Environment Department of the State of Rio Grande do Sul were trained in the use of this version, prepared for the field trial, according to the design proposed by WHO. RESULTS: The results refer to a study about reliability of diagnosis attributed by 9 pairs of CGP to 460 patients in their first appointments. Cohen's Kappa for Mental Health Disorder, present or absent, was 0,79 (CI 95%: 0,69 - 0,88). CONCLUSION: The use of ICD-10 CP will give more specificity to the information and will allow a better communication between health workers at the level of primary care     

COOP/WONCA charts as a screen for mental disorders in primary care

PURPOSE Most people with mental disorders receive treatment in primary care. The charts developed by the Dartmouth Primary Care Cooperative Research Network (COOP) and the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA) have not yet been evaluated as a screen for these disorders, using a structured psychiatric interview by an expert or considering diagnoses other than depression. We evaluated the validity and feasibility of the COOP/WONCA Charts as a mental disorders screen by comparing them both with other questionnaires previously validated and with the assessment of a mental health specialist using a structured diagnostic interview.METHODS We trained community health workers and nurse assistants working in a collaborative mental health care model to administer the COOP/WONCA Charts, the 20-item Self-Reporting Questionnaire (SRQ-20), and the World Health Organization–Five Well-Being Index (WHO-5) to 120 primary care patients. A psychiatrist blinded to the patients’ results on these questionnaires administered the SCID, or Structured Clinical Interview for the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).RESULTS The area under the receiver operating characteristic curve was at least 0.80 for single items, a 3-item combination, and the total score of the COOP/ WONCA Charts, as well as for the SRQ-20 and the WHO-5, for screening both for all mental disorders and for depressive disorders. The accuracy, sensitivity, specificity, and positive and negative predictive values of these measures ranged between 0.77 and 0.92. Community health workers and nurse assistants rated the understandability, ease of use, and clinical relevance of all 3 questionnaires as satisfactory.CONCLUSIONS One-time assessment of patients with the COOP/WONCA Charts is a valid and feasible option for screening for mental disorders by primary care teams.     

Poverty and common mental disorders in developing countries

A review of English-language journals published since 1990 and three global mental health reports identified 11 community studies on the association between poverty and common mental disorders in six low- and middle-income countries. Most studies showed an association between indicators of poverty and the risk of mental disorders, the most consistent association being with low levels of education. A review of articles exploring the mechanism of the relationship suggested weak evidence to support a specific association with income levels. Factors such as the experience of insecurity and hopelessness, rapid social change and the risks of violence and physical ill-health may explain the greater vulnerability of the poor to common mental disorders. The direct and indirect costs of mental ill-health worsen the economic condition, setting up a vicious cycle of poverty and mental disorder. Common mental disorders need to be placed alongside other diseases associated with poverty by policy-makers and donors. Programmes such as investment in education and provision of microcredit may have unanticipated benefits in reducing the risk of mental disorders. Secondary prevention must focus on strengthening the ability of primary care services to provide effective treatment.     

The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients.

PURPOSE: To investigate the validity of the Patient Health Questionnaire for Adolescents (PHQ-A), a self-administered instrument that assesses anxiety, eating, mood, and substance use disorders among adolescent primary care patients. METHODS: A total of 403 adolescents from California, New Jersey, New York, and Ohio completed the PHQ-A and the Medical Outcomes Study Short-Form General Health Survey (SF-20) during or shortly after a visit to a primary care clinic or a school nurse's office. A few days later, clinical psychologists who were blind to the results of the PHQ-A administered a semi-structured clinical interview to assess the same psychiatric disorders and to conduct a global assessment of functioning (GAF) among 403 patients. Diagnostic agreement coefficients were computed and analyses of covariance were conducted. RESULTS: Findings support the diagnostic validity of the PHQ-A. The PHQ-A and the clinical interview produced similar estimates of the prevalence rates of anxiety, eating, mood, and substance use disorders. The PHQ-A demonstrated satisfactory sensitivity, specificity, diagnostic agreement, and overall diagnostic accuracy, compared with the clinical interview. Adolescents with PHQ-A diagnoses experienced significantly poorer mental and overall functioning, more physical pain, and poorer overall health compared with those without psychiatric disorders. These differences remained significant after patients' age, gender, ethnicity, and site were controlled statistically. CONCLUSION: The PHQ-A may be used to assist primary care practitioners in identifying psychiatric disorders among their adolescent patients. The PHQ-A is the first such tool to be tested for use in adolescents and offers an acceptable and efficient tool for early detection and recognition of mental disorders in this high-risk group.     

Patterns of health services use and costs in patients with mental disorders in primary care

OBJECTIVES: To determine the pattern of services use and costs of patients requiring care for mental disorders (MD) in primary care in the context of routine clinical practice. METHODS: We performed a retrospective study of patients older than 15 consulting primary care at least once for MD, attended by 5 primary care teams in 2004. A comparative group was formed with the remaining outpatients without MD. The main measurements were age, gender, case-mix/comorbidity and health resource utilization and corresponding outpatient costs (drugs, diagnostic tests and visits). Multiple logistic regression analysis and ANCOVA models were applied. RESULTS: A total of 64,072 patients were assessed, of which 11,128 had some type of MD (17.4%; 95% CI, 16.7-18.1). Patients consulting for MD had a greater number of health problems (6.7 vs. 4.7; p < 0.0001) and higher resource consumption, mainly all-type medical visits/patient/year (10.7 vs. 7.2; p < 0.0001). The mean annual cost per patient was higher for patients with MD (851.5 vs. 519.2 euros; p < 0.0001), and this difference remained significant after adjusting by age, sex and comorbidities, with a differential cost of euros 72.7 (95% CI, 59.2-85.9). All components of outpatient management costs were significantly higher in the MD group. CONCLUSIONS: Outpatients seeking care for some type of MD had a high number of comorbidities and showed greater annual cost per patient in the primary care setting.     

Predicting the duration of sickness absence for patients with common mental disorders in occupational health care

OBJECTIVES: This study attempted to determine the factors that best predict the duration of absence from work among employees with common mental disorders. METHODS: A cohort of 188 employees, of whom 102 were teachers, on sick leave with common mental disorders was followed for 1 year. Only information potentially available to the occupational physician during a first consultation was included in the predictive model. The predictive power of the variables was tested using Cox's regression analysis with a stepwise backward selection procedure. The hazard ratios (HR) from the final model were used to deduce a simple prediction rule. The resulting prognostic scores were then used to predict the probability of not returning to work after 3, 6, and 12 months. Calculating the area under the curve from the ROC (receiver operating characteristic) curve tested the discriminative ability of the prediction rule. RESULTS: The final Cox's regression model produced the following four predictors of a longer time until return to work: age older than 50 years [HR 0.5, 95% confidence interval (95% CI) 0.3-0.8], expectation of duration absence longer than 3 months (HR 0.5, 95% CI 0.3-0.8), higher educational level (HR 0.5, 95% CI 0.3-0.8), and diagnosis depression or anxiety disorder (HR 0.7, 95% CI 0.4-0.9). The resulting prognostic score yielded areas under the curves ranging from 0.68 to 0.73, which represent acceptable discrimination of the rule. CONCLUSIONS: A prediction rule based on four simple variables can be used by occupational physicians to identify unfavorable cases and to predict the duration of sickness absence.     

Quality assurance of outcome in mental health care: a model for routine use in clinical settings.

A problem-oriented method of quality assurance of clinical outcome was used in 1,384 patients who were assessed and treated over 8 years by 41 nurse therapist trainees. The clinical audit suggested that for most diagnoses patients' improvement after treatment was usually satisfactory. Though the system was developed to monitor the progress of patients with anxiety, sexual and habit disorders having behavioural psychotherapy, it could also be applied to other disorders like depression and to other treatments. The method is simple enough for routine use, and computerisation would put it within the grasp of most clinics and training programs for all mental health care professionals.