A Integracao de Saude Mental na Atencao Basica:

1. A Integracao de Saude Mental na Atencao Basica: Defining the Roles and Challenges in the Family Health Program Anh Tuyet Vuong FIOCRUZ CSEGSF/ENSP Georgetown University School of Nursing and Health Studies December 5, 2008

2. Introduction • Mental illness accounts for 7 out of top 10 causes of DALYs • Large treatment gaps: • 55% of patients depression are not treated • 77% of anxiety disorders are not detected • Impacts health, social relationships, family structure and work/economics

3. Importance of the Integration of Mental Health in Primary Care • Reduces stigma- treated alongside primary care patients • Improves accessibility • More Humane in comparison to mental asylums • Less disruptions, people can remain with families and communities • Cost-effective and produces good health outcomes • Cheaper to treat cases at primary care level than secondary & tertiary • Mentally ill use more health care resources • Shared Resources • Coordination of activities between PHC and MH professionals reduces burden of tasks

4. Mental Health and Physical Health • Mental illness affect and are affected by somatic health conditions • Mentally ill die an average of 20 years earlier than the average person • Integrating MH and PHC improves treatment of health problems for mentally ill as well as improves treatment of psychological concerns for the physically ill

5. High Prevalence of Mental Disorders Link between Mental and Physical Health Large Treatment Gap Enhanced Access Respects Human Rights Reduction of Stigma Cost-Effectiveness Good Health Outcomes

6. Objetivos • Define and identify roles, responsibilities, strengths and weaknesses of health professionals and mental heatlh professionals • Understand perceptions, knowledge and approaches to mental health of professionals • Examine barriers and facilitating factors to detection, diagnosis, treatment and care of the mentally ill within the Manguinhos community

7. Methologia • 11 semi-structured interviews were conducted regarding perceptions of mental health within the community, challenges and facilitating factors • 6 ACS • 2 mental health professionals • 1 technica de enfermagem • 2 enfermeros • Diario de Campo was used to record generaly observations from domestic visits, patient consulations and family health team meetings.

8. Resultados

9. Contexto da Comunidade • High rates of poverty, cramped living conditions, unemployment and prevalent violence • Common Mental Illnesses: Depression, anxiety, psychosomatic illnesses and mood disorders • Low stigma against mentally illness because of violence and other concerns • Could facilitate treatment or it could desensitize people and hinder care-seeking behavior • Knowledge about mental health concepts and mental illness in the community is limited

10. Roles of Health Professions in Mental Health Cases Self or Family seeks care Nurse Doctor Nurse Technician Secondary & Tertiary care Mental Health Professional ACS Community Referral

11. Two Perspectives on the Integration of Mental Health into ESF

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

13. Advantages of ESF • Closer to the family • Trust of the residents • A deeper understanding of community dynamics and patient’s history • Live within the community • More access to mentally ill who are isolated • Knows the community resources and rules

14. Exclusive Perspective • Psychiatry is a very specialized field • Handling cases of mental illness requires specialized training and education • Without appropriate training • Frustrations and burn-out from not being able to handle cases • ineffectively, could possibly harm patients

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

16. “We have things that we cannot achieve and sometimes, we think that we should just leave it alone and not bother with it. Because sometimes, it is a lot easier to abandon the work than to put out the effort and try…There are many people out there who already have lost hope” -ACS, Equipe 2

17. Balancing the Two Views • Inclusion of other health professionals of the ESF leads to more holistic care • Clearly defining roles and responsibilities, supported by appropriate training ensures quality cared delivered by qualified professionals • “The mental health team is starting to try to work with the family health teams and give them support and our time and expertise. We are trying to work with the family health teams at the primary level, while maintaining the secondary levels also. After a while, maybe we can strike a better balance.” (Psychologist)

18. Conditions for the Successful integration of MH into PHC • PHC staff must have knowledge, skills and motivation to treat and manage mentally ill • Sufficient MH professionals • Psychotropic drugs must be available • Wide range of services that responds to individuals and populations • Well-defined roles and responsibilities • Strong links • between MH and PHC professionals, recording systems for monitoring and evaluation • Between primary, secondary and tertiary • With community

19. Recommendations • Psychological support for health professionals, especially for ACS • Integration of mental health activities into pre-existing health promotion programs for specialized populations • Improvement of the links and interactions between MH professionals and ESF, especially ACS • Increased training for ACSs and ESF in mental health

20. Conclusions • The health center has an excellent model for the integration of mental health into primary care • However, integration is process • Detected cases are generally well handled, however there is still a treatment gap • Improving connections between ESF and SM professionals as well as improved training in SM

21. Who is more crazy? “Individual isolated cases of foolishness and personal insanity are not as terrible as the widespread, organized, widespread social insanity of our world.” -Leo Tolstoy

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