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Integrating mental health into primary health care in Bangladesh: problems and prospects

S.M. Yasir Arafat

Resident, Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

E-mail : aa

Susmita Roy

Associate Professor, Department of Psychiatry, Jalalabad Ragib Rabeya Medical College, Sylhet, Bangladesh

Nafisa Huq

Senior lecturer and Coordinator, School of Public Health, Independent University, Bangladesh

DOI: 10.15761/MHAR.1000158

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Introduction

Integrating specialised health services such as mental health services into primary health care (PHC) is one of the most fundamental health care recommendations of World Health Organization (WHO) [1]. Primary mental health care facilitates is central to the values and principles of the Alma Ata Declaration [2]. Providing mental health services in PHC involves diagnosing and treating people with mental disorders; putting in place strategies to prevent mental disorders and ensuring that PHC workers are able to apply key psychosocial and behavioural science skills like interviewing, counselling and interpersonal skills in their day to day work in order to improve overall health outcomes [3]. Integrated primary mental health services are usually complemented with tertiary and secondary level mental health services like general hospital services to manage acute episodes of mental illness, half way home, community residential facilities and so forth. However, despite relevant need for primary mental health care services, Bangladesh is yet to holistically integrate mental health into its primary health care system.

The burden of mental health disorders in Bangladesh is yet to be measured precisely as done in the developed countries. A recent systemic review reported the prevalence of mental disorders is to vary from 6.5 to 31.0% among adults and 3.4 to 22.9% among children in the country [4]. Mental health services are concentrated around tertiary care hospitals in big cities and there is little awareness regarding mental health disorders at the community level [4]. A substantial percentage of people suffering from mental health disorders report to a range of traditional health care providers like kabiraj, totka, faith healers (pirs and fakirs), homeopathic practitioners, rural medical practitioners (village doctors), community health workers and retail medicine sellers as their first point of contact for health care [5-8]. Uddin et al., found among 21 clozapine treated patients that, about 52% (11) of the respondents contacted first time the traditional healers, 14% contacted general physicians and only one in three patients consulted the psychiatrist [6]. Arafat et al., found in 120 schizophrenic patients that for their illness about 59% patients the traditional healers, 27% consulted general physicians, and only 14% consulted psychiatrist as first line service provider [7]. Bithika Mali studied 120 respondents with suicidal ideation in a tertiary care hospital of Dhaka city where she found that about 43% of the respondents visited traditional healers, about 23% visited the general physicians (GPs) and about 34% visited psychiatrist as first line service provider [8]. Such repeated evidences suggest that more than two-third of patients are visiting other than the mental health professionals [6-8]. Moreover, health literacy in poor in Bangladesh that further complicates to get proper health services [9,10]. Previous study revealed that up to 83% of committed suicides have had contacts with primary care physicians within a year and two third of them within a month [11]. A meta-analysis of studies regarding general practitioners’ ability to recognize mild depression showed a detection sensitivity of only 56.5% [12]. However, there is cost-effective treatment for depression and timely screening, treatment and follow up can reduce morbidity and mortality associated with depression [13]. Depression is a significant cause of suicide and recent evidences suggest that the use of antidepressants in the primary care level accelerates suicide reduction [11]. Addressing, screening, treatment and follow up of the depressed patients in PHC is a very important strategy to reduce suicide [11,14,15]. Treating mood disorders is a central approach of suicide prevention and primary care can be a very potential area for the same. Improved and regular screening of depressed patients with better treatment subsequently should be ensured in the primary care level [11]. In Iran there was a reduction in the rate of suicide completion in the intervention region compared to the control site where many programs were attempted to improve the knowledge and skills of GPs in regard to the screening, detection, and management of depression, and some methods were appeared more effective than others [16].

Bangladesh is a densely populated country having population density 1063 per square kilometer and total population is about 160 million [17]. Health sector is advancing dramatically with its existing manpower significantly empowering the primary health care [17]. However, the referral system between the care levels is very poor in Bangladesh [17]. Hence, to provide the better mental health coverage and services integration of mental health support with PHC is somewhat obligatory. There are options of general physicians training in assessing, planning and prescribing the common mental health problems but they are insufficient in frequency and quantity due to different factors such as fund problem [18]. Furthermore, motivations and enthusiasm in training provisions of GPs seem to be inadequate. Human, logistic and financial resources for mental health in terms of psychiatrists, psychologists, psychiatric nurses, social workers, occupational therapists, hospital bed, community services allocation and budget for mental health are extremely poor [19].

As the burden of mental disorders in Bangladesh is high and the benefits of integrating mental health in primary care are enormous in terms of reducing disease burden, treatment gap and cost burden for individuals and families, promoting respect for human rights and overall good health outcomes [20]. Adequate training during undergraduate education, refreshers training and continued medical education in mental health for primary care physicians is crucial for identifying individuals with mental health disorders in primary care [21]. Considering the scarcity of human resources for health and that a majority of the people access informal providers in Bangladesh, training the traditional healers under the formal umbrella subject to required rules and regulations may be explored. Utilizing the informal sector may not only reduce load on the existing human resource crisis but facilitate in reducing stigma associated with mental health disorders [22]. Feasible collaboration and communication with the secondary and tertiary level specialist services using modern technology cannot be underestimated [23]. The primary care focused mental health care and general practice focusing on screening, detection, treatment, referral and follow up of the depression and other mental disorder can play as the most effective way of covering the majority of the mental health patients at community level [l1]. Tele psychiatric approach such as video conferencing, teleconferencing consulting methods can be used to support the primary care services [11,24]. Furthermore, extensive research can pave pathways to what works and what does not.

Bangladesh has demonstrated good leadership and capacity in successfully integrating specialized health services like maternal and child health in PHC followed by significant reduction in maternal and under-5 child mortality rates to targets set by the Millennium Development Goal (MDG) [17,25,26]. Similar commitment and leadership is likely to facilitate integration of mental health in the PHC system in Bangladesh.

Conflict

None

Funding

Self-funded

References

  1. The World Health Report (2001) Mental Health: New Understanding, New Hope. Geneva: World Health Organization.
  2. WHO (1978) Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR.
  3. World Health Organization (2003) WHO Module on Human Resources and Training in Mental Health. Geneva: World Health Organization.
  4. Hossain MD, Ahmed HU, Chowdhury WA, Niessen LW, Alam DS (2014) Mental disorders in Bangladesh: a systematic review. BMC Psychiatry 14: 216. [Crossref]
  5. Monzur MSE, Taher A, Roy S, Karim ME, Mollah AH (2016) Pattern of psychiatric morbidity among the patients attended at psychiatric outpatient department. Bang J Psychiatry 30: 10-13.
  6. Uddin MS, Ahmed S, Arafat SMY (2017) Profile of Clozapine Therapy: A Cross Sectional Piloting in a Tertiary Care Setting of Bangladesh. J Psychiatry Psychiatr Disord 1: 190-198.
  7. Arafat SMY, Mali B, Akter H (2018) Proportion and reasons for medication non-compliance among schizophrenics: A cross-sectional observation in a tertiary care hospital of Bangladesh. Asian J Psychiatr 35: 52-54. [Crossref]
  8. Mali B (2018) Suicidal Ideation among Psychiatric Patients in a Tertiary Hospital in Bangladesh. National Institute of advanced Nursing Education & Research (NIANER), Dhaka, Bangladesh.
  9. Arafat SMY, Ahmed S (2017) Burden of Misconception in Sexual Health Care Setting: A Cross-Sectional Investigation among the Patients Attending a Psychiatric Sex Clinic of Bangladesh. Psychiatry J 2017: 4. [Crossref]
  10. Arafat SMY, Majumder MAA, Kabir R, Papadopoulos K, Uddin MS (2018) Health Literacy in School In: Papalois and Theodosopoulou, editors. Optimizing health literacy for improved clinical practices. Hershey, PA: Medical Information Science Reference 175-197.
  11. Arafat SMY, Kabir R (2017) Suicide prevention strategies: Which one to consider? South East Asia J Public Heal 7: 1-5.
  12. Mitchell AJ, Rao S, Vaze A (2011) Can general practitioners identify people with distress and milddepression? A meta-analysis of clinical accuracy. J Affect Disord 130: 26-36. [Crossref]
  13. Wang PS, Simon G, Kessler RC (2003) The economic burden of depression and the cost-effectiveness of treatment. Int J Methods Psychiatr Res 12: 22-33. [Crossref]
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  15.  Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, et al. (2005) Suicide prevention strategies: a systematic review. JAMA 294: 2064-2074. [Crossref]
  16. Malakouti SK, Nojomi M, Poshtmashadi M, HakimShooshtari M, Mansouri Moghadam F, et al. (2015) Integrating a suicide prevention program into the primary health care network: a field trial study in Iran. Med J Islam Repub Iran 29: 208. [Crossref]
  17. Arafat SMY (2016) Doctor Patient Relationship: An untouched issue in Bangladesh. Int J Psychiatry 1: 2.
  18. Report of the assessment of the mental health system in Bangladesh using the World Health Organization (20017)- Assessment Instrument for Mental Health Systems (WHO-AIMS). Dhaka, Bangladesh.
  19. Islam A, Biswas T (2015) Mental Health and the Health System in Bangladesh: Situation Analysis of a Neglected Domain. J Psychiatry Neurosci 3(4): 57-62.
  20. Funk M, Saraceno B, Drew N, Faydi E (2008) Integrating mental health into primary healthcare. Ment Health Fam Med 5: 5-8. [Crossref]
  21. Ballester DA, Filippon AP, Braga C, Andreoli SB (2005) The general practitioner and mental health problems: challenges and strategies for medical education. Sao Paulo Med J 123: 72-6.
  22. Sorsdahl K, Stein DJ, Grimsrud A, Seedat S, Flisher AJ, et al. (2009) Traditional healers in the treatment of common mental disorders in South Africa. J Nerv Ment Dis 197: 434-441. [Crossref]
  23. World Health Organization (2003) WHO Module on Organization of Services for Mental Health. Geneva: World Health Organization.
  24. World Health Organization (2006) The World Health Report 2006 - Working together for health. Geneva: World Health Organization.
  25. El Arifeen S, Hill K, Ahsan KZ, Jamil K, Nahar Q, et al. (2014) Maternal mortality in Bangladesh: a Countdown to 2015 country case study. Lancet 384: 1366-1374. [Crossref]
  26. Ministry of Health and Family Welfare, Bangladesh, Partnership for Maternal, Newborn & Child Health, WHO, World Bank and Alliance for Health Policy and Systems Research. Success Factors for Women’s and Children’s Health (2015) Bangladesh: Ministry of Health and Family Welfare.

Editorial Information

Editor-in-Chief

Jeffrey L. Derevensky
McGill University

Article Type

Short Communication

Publication history

Received: June 20, 2018
Accepted: June 26, 2018
Published: June 30, 2018

Copyright

©2018 SM Yasir Arafat, Susmita Roy, Nafisa Huq. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Arafat SMY (2018) Integrating mental health into primary health care in Bangladesh: problems and prospects. Ment Health Addict Res 3: DOI: 10.15761/MHAR.1000158

Corresponding author

S.M. Yasir Arafat

Resident, Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Tel: +8801713272917

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