Background
Elements of a mental health care delivery platform
Self-care and informal health care
Primary health care
Specialist health care
Psychiatric services in general hospitals and community mental health services
Extended-stay facilities and specialist psychiatric services
Relationships between different delivery channels
Evidence-based interventions for health care delivery platforms
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Promotion and primary prevention
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Identification and case detection
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Treatment, care, and rehabilitation.
Delivery channel | Promotion and primary prevention | Identification and case detection | Treatment, care, and rehabilitation |
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Self-care and informal health care | Adoption of a healthy lifestyle, including diet and physical activity relaxation training Self-monitoring of high risk behaviors, such as substance abuse | Self-detection of depression and anxiety disorders | Web-based psychological therapy for depression and anxiety disorders Self-managed treatment of migraine Self-identification and management of seizure triggers Improving adherence to anti-epileptic treatment by intensive reminders and implementation intention interventions |
Primary health care | Parent skills training for internalizing and externalizing problems in child and parental mental health | Screening for developmental delays in children Screening and brief interventions for alcohol use disorders by trained primary health care staff Community-based case finding of psychosis and severe depression Diagnosis of depression, anxiety disorders, maternal depression, alcohol use disorders, dementia, headaches, and epilepsy | Management—pharmacological and psychosocial interventions—of depression, anxiety, psychosis, bipolar disorder, alcohol use disorders, epilepsy, dementia, and drug use based on mhGAP Intervention Guidelines Psychological treatment for depression, anxiety, ADHD, disruptive behaviour disorders in children Cognitive behavioral therapy-based interventions for depression and anxiety disorders in adults and mothers in perinatal period Management of alcohol withdrawal in conjunction with motivational interviewing and motivation enhancement involving family and friends Interventions for caregivers of patients with psychosis and dementia Improve quality of antenatal and perinatal care to reduce risk factors associated with intellectual disability Primary healthcare packages for underlying MNS disorders (for suicide and self-harm) Planned follow-up and monitoring of suicide attempters Emergency management of poisoning |
Specialist health care | Diagnosis of complex childhood mental disorders Diagnosis of severe psychosis and depression Diagnosis of secondary causes of headache Screening of new-born babies for modifiable risk factors for intellectual disability | Electroconvulsive therapy for severe refractory depression Surgical interventions for refractory epilepsy Pharmacological management of dementia (cholinesterase inhibitors and memantine) Methadone maintenance therapy for opioid dependence, buprenorphine as opioid substitution therapy Management of refractory psychosis using clozapine Management of severe alcohol dependence (along with withdrawal) Management of severe maternal depression using antidepressants Stimulant medication for severe cases of attention deficit hyperactivity disorder Cognitive behavioral therapy based interventions and anger control training for adolescents with disruptive behavioral disorders |
System strengthening strategies for integrated health care delivery
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A whole-of government approach involves the promotion, pursuit, and protection of health through concerted action by many sectors of government. These include ministries of planning and development, finance, law and justice, labor, education, and social welfare. The health system cannot tackle the health, social, and economic determinants and consequences of MNS disorders alone.
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A public health approach stresses the establishment of partnerships between patient and service providers, as well as equitable access for the whole population [17]. This approach requires the integration of care at the patient level. Services should be person-centered and coordinated across diseases and settings. Collaborative, coordinated, and continuing care, within a framework of evidence-based interventions, provides the foundation of the public health approach. This means providing good-quality, accessible services to those in need, as well as preventing the onset of disease and promoting mental health and well-being over the entire life course [18].
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A systems approach to integrated service planning and development encompasses the critical ingredients of a health system—good governance, appropriate resourcing, timely information, as well as the actual delivery of health services or technologies—that need to be in place for desired health outcomes or program goals to be realized. Effective governance, strong leadership, and cogent policy-making merit particular mention, since they provide the framework for appropriate action and subsequent service development. Indeed, a well-articulated mental health policy, along with a clear mental health implementation plan and budget, is a strong driver for change and can appreciably boost efforts to deliver mental health services at primary care level [16].
Strategy 1. Improving the organization and delivery of services through collaborative stepped care
Strategy 2. Strengthening human resources for mental health through task sharing
Task-sharing approach
Competency-based and continuing education
Specialist transitioning
Planning and consultation
Psychotropic medications
Strategy 3. Integrating mental health into existing health care delivery channels
Maternal and child health programs
Noncommunicable disease programs
HIV/AIDS and tuberculosis programs
Resource estimation
Quality of care for MNS disorders
Conclusions
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To deliver interventions for MNS disorders, the focus needs to move from vertical programs to horizontal health service platforms.
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The WHO pyramid framework of self-care, primary care, and specialist care continues to provide a useful approach for understanding potential delivery channels.
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A set of evidence-based interventions within this framework can be identified for promotion/prevention, identification/case detection, and treatment/care/rehabilitation interventions.
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The delivery of these interventions requires an approach that embraces public health, systems, and whole of government principles.
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The key strategies for this delivery are implementing collaborative stepped care, strengthening human resources, and integrating mental health into general health care.
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Finally, it is not only important to improve access to health services for MNS disorders but also to focus on improving the quality of care delivered.