Mental health is increasingly recognised as a significant aspect relating to the overall well-being of the individual. This year World Mental Health Day, which falls on October 10, has been dedicated to “Mental Health in Primary Care: Enhancing Treatment and Promoting Mental Health”. Mental health issues are a global priority and it is absolutely necessary to address issues pertaining to it at the earliest and in an effective and efficacious manner.

The World Health Organization has identified the following 7 reasons for integrating mental health into the primary care setting,

• The burden of mental disorders is great. They create a substantial personal burden for affected individuals and their families, and they produce significant economic and social hardships that affect society as a whole.
  
  
• Mental and physical health problems are interwoven. Integrated primary care services help ensure that people are treated in a holistic manner.
  
  
• The treatment gap for mental disorders is enormous. There is a significant gap between the prevalence of mental disorders and the number of people receiving treatment.
  
  
• Primary care for mental health enhances access. When mental health is integrated into primary care, people can access mental health services closer to their homes. It also facilitates community outreach and mental health promotion.
  
  
• Primary care for mental health promotes respect of human rights.
  
  
• Primary care for mental health is affordable and cost effective. Primary care services for mental health are less expensive than psychiatric hospitals, for patients, communities and governments alike.
  
  
• Primary care for mental health generates good health outcomes. The majority of people with mental disorders treated in primary care have good outcomes, particularly when linked to a network of services at secondary level and in the community.
  

At present, if we look at the Indian scenario we need to keep in mind the population of our country and the fact that maximal population resides not in the metropolitan cities but in the smaller cities, towns, and villages. Surveys have clearly reflected the predominant availability of mental health professionals – psychiatrists, psychologists, psychiatric social workers – in metropolitan cities. Thus there is a glaring disparity between the availability of mental health services in the larger cities and those available in other parts of the country.

Furthermore, there is also a recognition of the general inadequacy of the number of available professionals. Documentation of the number of available psychiatrists and psychologists has revealed that there is a 330% shortage of psychologists and a 200% shortage of psychiatrists in our country. As a result, the number of patients that need to be seen and that are actually seen is not concordant.

It has been suggested that the integration of mental health services within the purview of the primary health care setting be initiated. It is felt that this integration of services would help align diagnosis, treatment, care, and rehabilitation of the individual. This would also help ensure that the same amount of significance is accorded to both these aspects of overall health and the associated stigma is also alleviated with the passage of time. Furthermore, there is an understanding that both mental and physical health have a reciprocal interaction and influence each other.

Given the present scenario in our country, it is easily recognisable that the maximum numbers of people tend to reach the general practitioners and medical professionals who work at the grassroots level. It is thus important for us to impart skills and competencies along with a good understanding to identify mental health related problems and provide the first line of treatment to the general practitioners who are working in the field of medicine. At the same time non-medical professionals such as village health workers, anganwaadi workers, non-governmental organisations, community based social workers and volunteers, and even teachers and school counsellors play a significant role in the early identification of any problems and concerns and thus help direct individuals in need to the right professionals who could help them resolve these issues.

It is thus necessary for us to ensure that through the integration of mental health within the primary care setting there can be more effective:

• Screening for psychiatric disorders leads to improved patient outcomes only when appropriate care follows detection.
  
  
• Physician education.
  
  
• Enhancing referrals to specialty behavioural health providers with additional supports may lead to improved follow-through and outcomes.
  
  
• Care needs to be co-ordinated and based in evidence-based approaches.
  

At the same time it is important to ensure that there are clearly delineated principles and steps regarding the line of treatment that should be provided to the general practitioners and primary care workers. Following the initial treatment by primary workers further referrals for difficult mental health problems and those that are not easily resolvable can be referred to specialist psychiatrists and psychologists.

Thus, policies are required to be designed and implemented by the government. This would mean that legislation is required and these issues need to be integrated into the general health policy which should be inclusive of not just medical or physical health but also psychological or mental health concerns. As a result, advocacy is required and is an important aspect of mental health. We would need to sensitise the leadership, health authorities, management and primary care workers about the necessity of integration of these two aspects of health. It is understandable that integration is a process and it would take time and it is absolutely essential to attain collaboration between the governmental sectors, governmental non-health sectors, non-governmental organisations, village and community health workers and volunteers. This can be summarised as follows as has also been suggested by the WHO as strategies for integrating mental health in primary care:

• Policy and plans need to incorporate primary care for mental health.
  
• Advocacy is an absolute essential.
  
• Adequate training needs to be imparted along with allocation of tasks that are doable.
  
• Sensitisation at different levels is an essential aspect.
  
• Collaboration is required between governmental and non-governmental organisations which work in the primary health care setting.
  
• There needs to be adequate allocation of financial resources and human resources to ensure the availability of services to maximum number of people.
  

Early and cost effective interventions need to be given primary importance. Some of the interventions that need to be incorporated include the following:

• Early intervention within schools by school counselors and by paediatricians.
  
• Provision of support to children through life skills education and skill building programmes.
  
• Mental health promotion activities in school.
  
• Specialised supportive services for women and elderly that cater to their needs and requirements.
  
• Mental health activities at the work place given the current levels of stress, impact on interpersonal relations, social functioning, levels of attrition and absenteeism.
  
• Community programmes to generate awareness and remove stigma associated with mental health related problems.
  

The recognition of the need for integration of services is particularly applicable within the context of a large and populous country like India, where due to the paucity of professionals there are millions of people who are not receiving the treatment that they urgently require. A step in the direction of integration would be beneficial to all – patients, their families, medical professionals, mental health professionals, non medical and non-governmental organisations working in the field for the promotion of the overall health and well-being of the individual and thus the community at large.