Time to integrate mental health

One of the challenges of my column is to look for current news related to mental health. Sometimes, a national topic demonstrates psychological issues quite nicely, but most of the time, mental health doesn’t really make it on the front page, despite it being one of the more long-running pandemics of our time. An article from yesterday’s paper featured a quote from Health Undersecretary Beverly Ho who said that, while there are only three mental health professionals per 100,000 Filipinos, increasing the number of mental health workers would mean establishing a “specialist-oriented system” that is not among the current priorities of the Department of Health (DOH). I was quite confused by this statement, and I’m hoping I simply misunderstood. This was, after all, an interview conducted at a mental health advocacy event mostly populated by nonmental health professionals. Perhaps assuring them that increasing mental health professionals isn’t a DOH priority was a way to placate the target audience.

This is something I’ve noticed in our local mental health political landscape: It is too territorial and segregated. Mental health advocacy and mental health care seem to be done in relative isolation from one another. Mental health care itself is not integrated: Medical-oriented mental health care focuses on psychiatric symptoms, medication, and hospitalization, while some counseling-oriented mental health care can sometimes give sole emphasis on social and environmental factors, willfully discounting interacting biological factors out of pure ideology. Lay advocacy can sometimes go to an extreme position, which eschews professional treatment altogether and thinks awareness alone is enough. Out of territorial pride, each perspective thinks one knows much better than the other.

This is further solidified by a lack of any institutional infrastructure that houses all these aspects together. DOH is overfocused on medical doctors (on a petty note: they can have a Philippine National Police undersecretary, but won’t ever appoint a psychologist or other allied fields?). Hospitals barely employ psychologists, and if they do, it is mostly for administration of standardized assessments supervised by psychiatry.

I’ve had the great happenstance of working often with multidisciplinary health teams, both locally and abroad, both in research and clinical practice, and know that a team that genuinely respects each other’s expertise and perspective provides much greater overall health care than putting disciplines in a hierarchy. A collaborative case conference—essentially a meeting among providers to discuss the best way to help a patient—comprising different professionals and family members of the patient can be quite exhilarating in its potential to find creative, systemic solutions, rather than focusing on a single symptom or a single treatment. Simply put, the best health care is when everyone works together.

In a complex phenomenon that is mental health, we need an integrated view. Moreover, we need an integrated health care system. I agree with Ho that primary health care should be able to have basic skills in assessing, treating, and referring mental health cases. However, a reliance on the World Health Organization’s Mental Health Gap Action Programme (mhGAP), which provides modular training and guidance on assessment of psychiatric symptoms and allows primary care physicians to prescribe psychoactive medication, requires review, since it seems that trained workers aren’t implementing the mhGAP due to lack of confidence and stigma around mental health.

Instead of simply adding the burden of mental health work to already beleaguered barangay health workers, my suggestion is to hire dedicated mental health workers to launch and supervise the program. We have an overabundance of licensed psychometricians who fail to find employment; with additional targeted training, they can be ready for this work. In another lifetime, I was trained as a behavior health consultant in a primary care facility. I served as a consultant to the providers themselves, not necessarily the patients. This was to help them with cases that include a mental health component, not just psychiatric conditions but also chronic pain and diseases, as well as medical conditions that require lifestyle changes like hypertension and diabetes.

The goal of primary care psychology is not necessarily to get clients referred to a mental health specialist, but to have a psychologist within primary care itself, ready to hop on a case and assist in case formulation and treatment. I also served to encourage physicians and nurses to tackle mental health-related cases instead of simply referring. It is high time we integrate mental health in primary care—and we need to do it together.

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