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October 2010, Volume 60, Issue 10

Editorial

Primary care psychiatry in Pakistan: Issues and challenges

Haider Ali Naqvi  ( Department of Psychiatry, The Aga Khan University, Karachi. )

The awareness campaign theme for this year\'s World Mental Health Day 2009 is Mental Health in Primary care: Enhancing Treatment and Promoting Mental Health, which goes a long way in establishing the due credence of primary care psychiatry.1 Definition of primary care has been given as: "Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health-care needs, developing a sustained partnership with patients, and practicing in the context of family and community."2 Primary care is expected to be a long-term relationship between a person and their doctor. Provision of mental health care through primary health care is popularly dubbed as primary care psychiatry.
World Health Organization (WHO) has taken a lead in providing the innovative approach for mental health care to masses in the context of developing countries, when there is dearth of specialist care providers. According to them, mental health care services should be integrated with general health services, provided in decentralized manner.3 Research in to the primary care psychiatry has not matched feet with the health service utilization. There are many reasons for this: funding in to the service research has lagged due to lack of expertise. In cases where such an expert manpower was available, an independent, unbiased research approach was missing. In the end, literature repeats the well spelled service-care-plan of primary care psychiatry envisioned in the Geneva — and subsequent regional head offices.2 Divorced from the realities of the primary care in developing countries, there are chinks in the armor, which could very well be observed by an incisive mind. 
Review of Health care systems in Pakistan indicates that, services are provided by three sectors; governments run health care system, private health care practitioners and alternative practitioners. In Pakistan 30 % of health care services are provided by government sector, while 70 % is taken care of by private health care systems.4 In Pakistan, primary care is struggling to deliver its own agenda (i.e. general health care), leave alone the mental health care of masses. Most Basic Health Units are underfunded and understaffed, with inadequate provision of essential medications.4 This results in a slipshod approach by the doctors.
The precious few examples of primary care psychiatry in Pakistan have come from the government run health care systems. Even there, the evidence on effectiveness of providing the integrated care calls for more systematic research. Some of the issues are related to perception of government run primary health care services by the general public, costs of treatment, knowledge and use of services, stigma attached to mental illness and care pathways.5 Most patients in Pakistan by-pass the primary care services and access services at secondary and tertiary care centers directly. In the absence of any kind of health insurance, most patients pay out of their own pockets.6 People in general feel that they get the real value-deal for their money considering the questionable quality of services offered at the government run centers.
In the scenario where almost 70% of the service is provided by private health care sector, the dynamics of this service sector cannot be ignored. We need systematic data before we can propose a public-private partnership. In a study carried out at tertiary care center in Karachi, 68% patients presented to a psychiatrist as the first care provider. In the care pathway to mental health specialist, only 18 % had a past contact with the primary care physician.7 In another survey, exploring the care pathways in psychosis, using Interview for retrospective assessment of age at onset of Schizophrenia and other psychosis (IROAS), only 5% patients made that initial contact with the primary care physicians. Around 43% cases were seen by the Psychiatrists as a first contact.8
Common mental disorders (CMD) are neurotic disorders presenting with anxiety and depressive symptoms. Prevalence of common mental disorders is estimated to be 30 % to 40% in primary care setting. Although CMD have been diagnosed in third of primary care attendees in developing Asian countries, primary care staff is generally reported to recognize only 10% of the cases.8 Even when CMDs are detected they remain inadequately treated; a recent survey of patients receiving psychopharmacological medicines, 50% did not know their diagnosis; 68.5% were unaware of the disease process; 71.2% were unaware of alternative treatments; 86.3% were not cautioned about the potential adverse effects of the drugs; 32.9% were unaware of the duration of treatment and in 82.2% of the participants an appropriate referral had not been discussed. For all aspects of education, patients prescribed psychopharmacological medications knew less as compared to those patients that were prescribed other medications. This study poses this question: are family physicians in Pakistan up to this task?9
Surely, there are issues with the primary care psychiatry which warrants systematic inquiry. Primary care is ecology with many determinants; economics of health care service is an important denominator in this inquiry. In the context of private health care, patient\'s referral to specialized care facility is seen as a disincentive by many physicians. Another issue is the knowledge, access and availability of such specialized care centers. Additionally, training and expertise of the primary care physicians has been a resounding issue in the literature. There are other reasons, besides the health care service issues, behind this under recognition and inadequate treatment. The most common among them is the perfidious presentation of syndromes: most patients with common mental disorder present with non-specific somatic symptoms, which could very well be due to underlying medical conditions.10 Additionally, physician\'s skill and time are important denominator to a desirable outcome of consultation. Consultation time is an important precursor for proper recognition and treatment of common mental disorders. However it has been demonstrated from experience that recognition and management of depression in primary care is not labour intensive.11
In the context of Medical education in Pakistan, psychiatry is not taught and examined as an essential subject in most medical colleges at an undergraduate level. The academic positions in the psychiatry department either remain unoccupied or serve as a locus of power-control for individual\'s own ambitions. Students\' given a choice, relegate psychiatry to more mainstream discourses. Therefore, once these students become physicians, the behavioural and psychological aspects of the diseases fall on their blind eye-spot.12
Primary care psychiatry does not deal with the treatment alone. Prevention is an important aspect of promoting mental health: primary prevention by teaching life skills, enhancing stress-coping strategies, reproductive health education, imparting parenting skills, advocacy for child and adolescent health, etc, are some of the important components of primary prevention. There are several models of innovation from South Asia in this aspect of health care delivery: In Iran, an entirely different pattern of collaboration is represented by having a tier of service below primary care, with responsibility for both physical and mental disorders. These are called \'health houses.\'13 Multipurpose community health workers are also demonstrated to deliver effective care at a community level.14 Similarly the Lady Health worker programme in Pakistan is expected to address the issues related to mental and physical health at a community level.15 However we are in need of more robust data, with clear outcome indicators in order to have an unbiased evaluation of such programmes.
The supply of psychiatrists in developing South East Asian countries is much smaller than that in the developed world (typically below 0.4/1000,000 versus 9-25/100,000), and predicates that primary care must be one of the main provider of mental health care for all forms of disorders. However, many developing countries are not only short of psychiatrists - they are short of physicians.16 Therefore primary care also needs to be strengthened in the context of developing countries. Communication and dialogue needs to be initiated between primary care physicians and psychiatry; for the sake of their patients they have to talk to each other. Psychiatrists need to play their role in supporting and training the primary care physicians in order to enhance the mental health services. Primary care physicians need to develop their skill in order to deliver effective care. There are issues, at the interface of primary care psychiatry, which need to be researched systematically. Primary care psychiatry can only fulfill its promise if all stake holders come together and work towards a common goal - an effective patient care. 
World Mental Health Day is observed every year on 10th October.

References

1.World Federation for Mental Health. Mental Health in Primary care: Enhancing treatment and promoting Health. (Online) 2009 (Cited 2009 September 1). Available from URL: www.WFMG.ORG.
2.World health Organization and WONCA. Integrating mental health in primary care: a global perspective. Geneva: WHO, 2008.
3.World Health Organization. The world health report. Mental health: new understanding, new hope. (Online) 2001 (Cited 2009 September 1). Available from URL: www.who.int/whr2001/ 2001/main/en/.
4.Khattak FH. Financing of health sector in Health economics and planning in Pakistan. Ad-Rays publishers, Islamabad; 1996: 44-61.
5.James S, Chisolm D, Murthy S, Kishor KK, Sekhar K, Saeed K, Mubashhar M. Demand for, Access to and use of community mental health care: Lesson from a demonstration project from India and Pakistan. Int J Soc Psych 2002; 48: 163-76.
6.World Health Report; Changing History. Statistical annexure. (Online) 2004 (Cited 2009 September 1). Available from URL: http://www.who.int/whr/2004/annex/en/.
7.Naqvi H. Psychosis: Through the keyhole. DAWN. Retrieved June 28, 2009 from http://.dawn.com/2009.
8.Patel V, Pereira J, Mann AH. Somatic and psychological models of common mental disorder in primary care in India. Psychol Med 1998; 28: 135-43.
9.Ganatra HA, Bhurgri H, Channa R, Bawany FA, Zafar SN, Chaudhry RI, Batool SH, Basit A, Asghar M, Saleem S, Naqvi H. Educating and informing patients receiving psychopharmacological medications: are family physicians in Pakistan up to the task?  PLoS One. 2009; 4: e4620. Epub 2009 Feb 27.
10.Schwenk TL, klinkman MS, Coyne JC.  Depression in the family physicians office: what the psychiatrist needs to know: The Michigan depression project. J Clin Psychiatry 1998; 59: 94-100.
11.Jalil M. Teach people how to catch fish. BMJ 2004; 328: 839.
12.Naqvi HA, Khan MM. Depression in primary care: difficulties and paradoxes. J Pak Med Assoc. 2005; 55: 393-8.
13.Mohit M. Mental health in Tehran in the context of the national mental health programme of Iran. In: Goldberg D, Thornicroft G (eds). Mental health in future cities. Maudsley Monograph No.
12. Hove: Psychology Press, 1998: 217-38.
14.Patel V, Cohen A. Mental health services in primary care in \'developing\' countries. World Psychiatry 2003; 2: 163-4.
15.Kareem S, Saeed K, Rana MH, Malik MH, Jenkin R. Pakistan Mental health country profile. Internat Rev Psychiat. 2004; 16: 83-92.
16.Goldberg D. Psychiatry and primary care. World Psychiatry 2003; 2: 153-7.

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