Community mental health in family medicine

Samuel YS Wong 黃仰山

HK Pract 2024;46:111-113

Story of Ms. Chu

Ms. Chu, a 64-year-old woman, has been experiencing a three-month history of sadness. She has a background of hypertension and a BMI of 24. Her last visit was four months ago for blood pressure control. Ms. Chu lives alone, having been divorced for many years, and her son recently got married and moved out, visiting her once a month. She reports problems with sleep, feeling tired, and a general lack of motivation. Although she used to enjoy swimming, she has stopped this activity in recent months. A recent trip to Japan with her son brought her temporary joy, but she felt depressed upon returning to her solitary life in Hong Kong. Despite questioning the purpose of life at times, she has no suicidal ideation.

Importance of Community Mental Health

Mental health problems represent a significant global burden. The World Health Organization (WHO) recommends that mental health treatment be integrated into primary care to address this issue effectively. In primary care settings, the prevalence of common mental health problems is notable, with mixed anxiety and depression being the most common. However, in Hong Kong, only 26% of individuals with these issues have consulted mental health services in the past year, and less than 10% have consulted family physicians.

Role of Family Doctors in Community Mental Health

Family doctors play a crucial role as the first point of contact for individuals with mental health issues. They enhance the continuity and coordination of care by providing holistic care that integrates physical, psychological, and social health. This approach helps reduce stigma and improves patient outcomes. Indeed, the World Organisation of Family Doctors (WONCA) emphasised the important role family doctors play in detecting and managing common mental health issues in the community. Core competencies of family doctors include the ability to detect and manage common mental health problems in primary care, management of physical health among people with severe mental health problems, and the knowledge to use a range of available resources in the community tailored to individual health needs. The detection and treatment of mental health problems in primary care settings allow the provision of holistic care that encompasses physical, psychological, and social health and continuity of care that builds trust.

Importance of Community Partnerships

Community partnerships are vital for enhancing the accessibility and detection of mental health issues. A patient-centred and community-based approach links social services and community resources to improve patient outcomes. Potential partners include non-governmental organisations (NGOs), mental health professionals, and local organisations. The potential areas of collaboration include:

Assessments: Conducting thorough evaluations of mental health status.

Psychological Interventions: Offering evidence-based psychological therapy and counselling services such as cognitive behavioural therapy, behavioural activation, problem-solving therapy, and other psychological therapies.

Monitoring and Medication Compliance: Ensuring patients adhere to treatment plans.

Early Detection: Identifying signs of deterioration early with information sharing with family doctors and other health professionals within a multidisciplinary team.

Non-Psychological and non-pharmacological Interventions: Implementing group exercise and other evidence-based activities such as those recommended by the National Institute of Clinical Excellence (NICE) Guideline.

Indeed, the NICE guideline in the management of common mental health issues includes both non-pharmacological and pharmacological interventions, with the most recent update in 2022 recommending the use of non-pharmacological interventions, including guided self-help for less severe mental health problems in the community.

In Hong Kong, a significant number of family doctors practice solo or in small groups, often lacking integrated psychological services within their practices. This, combined with limited consultation time, underscores the essential role of allied health professionals in delivering optimal mental health care. These professionals include clinical psychologists, occupational therapists, social workers, counsellors, well-being practitioners, and physical trainers. They provide significant support to individuals with common mental health problems by working with family doctors in offering specialised interventions.

Potential Models of Mental Healthcare

To illustrate various potential models of mental healthcare for common mental health problems in primary care, a few examples are shown below.

The Mood Disorders Association of British Columbia (MDABC) Model:

The MDABC improves psychiatric access and offers long-term follow-up care for patients with mild to moderate mood and anxiety disorders in British Columbia by offering a “one-stop shop” for psychiatric assessment and follow-up services for family physicians. This results in improvement in efficiency with an overall reduction of per-patient cost and visit time. By using newer technologies, including emails, online booking, and group-based follow-up services, the model demonstrated a potential cost-effective way to increase mental health services at a lower cost and high satisfaction levels among both family physicians and patients.

The Foundry Initiative:

Using a stepped care approach, the Foundry initiative provides youths with integrated mental health and substance use services with easily accessible walk-in service hubs in the community. The intensity of interventions corresponds to the severity and preference of youths, allowing flexibility to increase engagement. Since its inception, there has been significant growth in the utilisation of services by youth with a high level of satisfaction and positive intervention outcomes.

The Integrated Mental Health Programme:

The Integrated Mental Health Programme (IMHP) was implemented in the Departments of Family Medicine of the Hospital Authority in 2010. This program includes family medicine centres and general outpatient clinics in the community and targets patients with common mental disorders (CMD) and employs protocol-driven management based on stratified risk levels. Patients were assessed and stratified by various risk levels with corresponding interventions based on risk levels. For those with mild risk, reassurance and lifestyle modification were advised. For those assessed with moderate risk, higher intensity of interventions provided by family medicine specialists and psychological interventions provided by allied healthcare professionals from non-governmental organisations or occupational therapists were provided within a multidisciplinary team setting. For people with severe risk, family medicine specialist review with pharmacotherapy, psychological services, and liaison meetings with psychiatrists were arranged to ensure optimal treatment was provided. The IMHP has shown positive outcomes with data provided, for example, by the New Territories East Cluster Department of Family Medicine, demonstrating a reduction in referrals to Psychiatry Specialist Outpatient Departments (SOPD) despite an increase in patients presenting with psychiatric symptoms in outpatient clinics. Family doctors also felt more supported and empowered to manage CMDs, leading to better collaboration with psychiatrists. Most importantly, there was a reduction in symptoms and severity of symptoms among patients with CMD.

Improving Access to Psychological Therapies (IAPT)

Two non-governmental organisations, the New Life Psychiatric Rehabilitation Association and Mind Hong Kong, are operating a pilot scheme in collaboration with District Health Centres to address common mental health problems in primary care. This scheme targets individuals with mild to moderate common mental disorders and offers brief structured individual guided self-help and psychological interventions in the community. The flexible service model includes face-to-face and video conferencing, utilising low-intensity Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT).

Strategies for Effective Collaboration, Challenges, and Future Directions

Effective collaboration requires building partnerships, developing clear goals, engaging with health professionals within a team setting with regular communication, and evaluating impact and outcomes. Facilitators for successful collaboration include trust, equal partnership, shared objectives, clear communication, close proximity, effective leadership, and adequate resources. Challenges to effective community mental health collaboration include a lack of training and resources, policy and payment barriers when working with different organisations, negative perceptions of NGO services by different health professionals, and administrative hurdles that deter health professionals in joining new initiatives or working with others. Future directions can focus on the provision of accessible and health professional-centred training and education, joint training programmes with mental health specialists, family physicians, and community mental health service providers, providing resources and guidelines for family doctors in the management of common mental health problems, and creating platforms for learning and collaboration.

In summary, common mental health problems are prevalent in the community. Family physicians, by working with community partners, play an important role in detecting and managing patients with CMD. Support, resources, and other facilitators are needed to engage fami ly physicians and mental hea l th professionals working in multidisciplinary teams so that people suffering from CMD can receive the most optimal treatment in the community.

Acknowledgements

I acknowledge the contributions of various professionals and organisations, including Dr. Eric Lee, Professor Stanley Hui, Dr. Maria Leung, Dr. Candy Wong Powell, Ms. Gladys Yeung, Dr. Benjamin Yip, Dr. Sun Yu Ying, Dr. Dexing Zhang, the Health and Medical Research Fund, and the Hong Kong Jockey Club Charities Trust.