1. Primary Care Mental Health Integration And The Evidence: Global Initiatives Dr Gabriel Ivbijaro MBBS FRCGP FWACPsych MMedSci DFFP MA Chair Wonca Working Party on Mental Health & Editor in Chief Mental Health in Family Medicine

2. There is no health without Mental Health

4. informal services

7. World Health Assembly Report 2009

9. Conventional health care vs primary people centred care

10. Current trends (WHO 2008) Too much emphasis on centralization can lead to: Increased fragmentation Reduced access Increased costs Difficulty attaining holistic care This emphasizes the need for primary care reforms

12. Lower overall costs

13. Generally healthier populations

14. Within countries, areas with:

15. Higher primary care physician (but NOT specialist) availability have healthier populations

17. An integrated primary care system Leadership is important at all levels Collaboration with policy makers Universality Appropriate skills and treatment available

18. mhGAP mental health Gap Action Programme Scaling up care for mental, neurological and substance use disorders Today, with the launch of the Mental Health Gap Action Programme, we have reached a critical juncture. The long-standing failure to take action and make progress against these disorders is no longer acceptable. There are no excuses anymore.  Dr Margaret Chan Director-General World Health Organization Launch of mhGAP Geneva, 9 October 2008

19. mhGAP mental health Gap Action Programme Scaling up care for mental, neurological and substance use disorders

20. Leading causes of years of life lived with disability (Both sexes, all ages)

21. Gap in treatment: Serious cases receiving no treatment during the last 12 months 90 85% 80 76% 70 60 50 50% 40 35% 30 20 10 0 Lower range Upper range Lower range Upper range Developed countries Developing countries (WHO World Mental Health Consortium, JAMA, June 2nd 2004) mhGAP 2009

22. High burden: 14% of the 2004 Global Burden of Disease measured in Disability-Adjusted Life Years (DALYs) attributable to mental, neurological and substance use disorders Large treatment gap: 76-85% in developing countries for serious mental disorders mhGAP 2009 Defining the challenge: A high burden and large treatment gap

24. Inconsistent and unclear advocacy between different groups of mental health advocates (professionals, users, families) and within each group

25. People with disorders are not organized in a powerful lobby in many countries mhGAP 2009

27. Public health training does not include mental health mhGAP 2009

28. Gap in human resources: Number of psychiatrists per 100,000 population

30. Providing technical support: Catalysing change at country level

31. A joint collaboration

32. Acknowledgements

33. Acknowledgements Other international contributors Wonca

38. The burden of mental disorders is great Mental and physical health problems are interwoven The treatment gap for mental disorders is enormous Primary care for mental disorders enhances access Primary care for mental disorders promotes respect of human rights Primary care for mental disorders is affordable and cost-effective Primary care for mental disorders generates goodhealth outcomes 7 good reasonsto integrate mental health into primary care

42. Lower overall costs

43. Generally healthier populations

44. Within countries, areas with:

45. Higher primary care physician (but NOT specialist) availability have healthier populations

49. Good health outcomes Compelling evidence available from a range of settings Primary care workers can Recognize a range of mental disorders Treat common mental disorders Deliver briefs interventions for the management of hazardous alcohol use Guidance available e.g. NICE guidelines

50. 12 best practices on 5 continents

51. Analysis of 12 best practice examples . United Kingdom . Argentina . Belize . Brazil . Chile . India . Iran . Saudi Arabia . Australia . South Africa (2) . Uganda

52. 10 principles for integrating mental health into primary care Policy and plans need to incorporate primary care for mental health. Advocacy is required to shift attitudes and behaviour. Adequate training of primary care workers is required. Primary care tasks must be limited and doable. Specialist mental health professionals and facilities must be available to support primary care. Patients must have access to essential psychotropic medications in primary care. Integration is a process, not an event. A mental health service coordinator is crucial. Collaboration with other government non-health sectors, nongovernmental organizations, village and community health workers, and volunteers is required. Financial and human resources are needed.

53. Report Conclusions Integration ensures that the population as a whole has access to the mental health care that it needs Integration increases the likelihood of positive outcomes for both mental and physical health problems Health planners embarking upon mental health integration should consider carefully the 10 broad principles outlined in the report Successful integration will also require reform in the broader health system.

54. Integration in NHS Waltham Forest, London, UK GP’s were asked to develop a Practice & Professional Development Plan (PPDP) Practice visits to support this from 2001-3 Included all practices in Waltham Forest Used proforma to collect data about practice in all clinical areas provided by family doctors Used the information to understand individual practice priorities and assess the standards of care patients were receiving 42

55. Clinical audits completed by GP Practices in 2001/2? 43

56. Practice targets as priorities for clinical improvement? 44

57. What did the PPDP visits tell us? Mental health was of low priority for most GP practices Management of long term physical conditions and IT were high priority Areas of high priority tended to have financial implications for GP practices 45

58. Mental Health In Waltham Forest 2008: A Summary

60. Standards achieved against outcome measures are above 80%

62. Integrated into the existing primary health services

63. Developing implementation strategies for community, primary and referral facility levels

64. Strengthening the health system supports required to deliver the interventions e.g. drugs, equipments

66. Wonca Collaboration