1. Integrating Mental Health
Services into Primary Care
Dr. Jibril Handuleh
Amoud University

2. Mental health in GP
practice
Mental illness is covert or hidden
Primary carers fail to recognize
one out of two patients with mental
illnesses
Incidence of mental illness varies
in different areas and practices and
at different times
Untreated mental illness is time-
consuming and costly

3. The cost of untreated mental
illness:
WHO “Burden of Disease” study
To patient
Morbidity, mortality, financial,
productivity, family suffering,
reputation
To community
Productivity, financial, loss of
community cohesion
To doctor
?

4. Obstacles to mental
health diagnosis
Patient
Ignorance, stigma, fear of the
implications, lack of finances or
resources to treat
Doctor
Knowledge and/or skill deficit,
attitude, misinterpretation or
interest issues, lack of facilities
and resources, time, remuneration
issues, discomfort with emotional
issues (personal or cultural)

5. Society
Different priorities, financial, lack of
community education, health
policy, community attitudes
What are the challenges in
Somaliland/Somalia practice???

6. Association Between Physical & Mental
Problems in Primary Care Patients
10-20% of general population will seek primary
care for a MH problem
Studies show prevalence of mental health
problems:
PRIME-MD: average 26% have psychiatric
disorder while another 13% have significant
functional impairment
WHO: average of 21% had psychiatric
disorders
2/3 of primary care patients with psychiatric
diagnosis have significant physical illness

7. COPYRIGHT © IAN M CHUNG 2005
The GP perspective
General practice is total (bio-psycho-social)
and should address continuing patient care in
the context of their family and community
The GP has an ongoing relationship with the
patient and their family
General practice provides opportunity for
early diagnosis before the condition is well-
defined or fully developed
The GP sees the patient before they are
“educated” by the process of investigation
and elimination

8. COPYRIGHT © IAN M CHUNG 2005
The main mental illnesses seen in
General Practice
Depression and anxiety are the major mental
illnesses, alone or co-morbid, or as
manifestations of other mental conditions or
medical illness
Both depression and anxiety have a range of
severity and forms
Specificity of diagnosis is important
Somatisation is very common: the mind and
body are one also patient prefers to c/o an
illness
Drug use and illness must be excluded
Any illness the GP needs to consider the full

9. Association Between Physical & Mental
Problems in Primary Care Patients
Chronic medical illness increases probability of depression by
two to three folds
Psychiatric disorders in primary care are less severe than
those in MH settings
Health status, quality of life, functional status-better correlated
with psychosocial factors than physical disease severity
Medical Outcome Study (MOS) indicates functional
impairment due to depression compares to that of COPD,
diabetes, CAD, hypertension, and arthritis

10. Recognition & Treatment of MH Problems
in Primary Care
1/2-2/3 of patients meeting criteria for psychiatric diagnosis go
unrecognized by primary care providers
Even when recognized & treated, dosage & duration of
antidepressant meds are usually inadequate
In naturalistic studies, there was no difference in outcome
between treated and untreated depressed patients in primary
care setting.

11. Health Care Utilization
Studies indicate objective disability or morbidity alone can predict
only 10-25% of health care use
One study found 60% of all medical visits were by “worried well”
with no diagnosable disorder
Patients with MH problems, when compared to unaffected
counterparts, use twice the medical resources.
Patients with somatization disorder use 9 times national norm of
medical resources

12. Why Should Primary Care Providers
Integrate MH Services Into Primary Care?
Primary Care Providers deal with patient’s untreated
psychological problem- identified or not
Psychosocial/behavioral problems take up Primary Care Provider
time regardless of degree to which problems are explicit focus of
practice
1/3-1/2 of Primary Care patients will refuse referral to MH
professional

13. Why Should Primary Care Providers
Integrate MH Services Into Primary Care?
Patients who refuse referral tend to be high utilizers with
unexplained physical symptoms
Dichotomizing patients problems into physical & mental leads to:
Duplication of effort
Undermines comprehensiveness of care
Hamstrings clinicians with incomplete data
Insures that the patient cannot be completely understood

14. Why Should Primary Care Providers
Integrate Mental Health Services Into
Primary Care?
Many prefer to receive MH services in Primary Care because not
construed as “mental healthcare”
With expectation of seriously mentally ill, basic MH services can
be managed in Primary Care setting
Growing evidence that integrated primary care is cost-effective

15. Conclusions
Mental healthcare cannot be divorced from primary
medical care - all attempts to do so are doomed to
failure
Primary care cannot be practiced without addressing
mental health concerns, and all attempts to neglect
them will result in inferior care
deGruy, F.V. (1997). Mental healthcare in the primary care setting:
A paradigm problem. Fam. Syst. & Health 15:3-26.

16. Barriers to Providing Mental Health
Services to Primary Care Patients
Competing Demands and Tasks of Primary Care Providers
Average primary care visit last 13 minutes
Patients have average of 6 problems on problem list
Inadequate time to adequately assess for mental health
problems and manage once assessed
A zero-sum game. No room for provision of new services
without eliminating another or adding resources for additional
work

17. Barriers to Providing Mental Health
Services to Primary Care Patients
Limitations of Specialty Mental Health Service for Primary
Care Setting
Focus of Psychiatry is increasingly on diagnosis of seriously
disturbed patients and prescription/monitoring of psychotropic
medication
Psychiatric diagnostic systems that do not fit clinical
phenomenology
Mental Health Providers not trained to address
psychological/behavioral problems common in primary care
settings
somatization
chronic pain
noncompliance with medical regimens

18. Barriers to Providing Mental Health
Services to Primary Care Patients
Patient Barriers to Providing Mental Health Services
Concerns about stigma of psychiatric diagnosis
Significant negative consequences for pursing mental health
care
Domestic abuse
Criticism from family
Patient Somatization: Problems not perceived as
psychological
Patient has no psychiatric diagnosis, but still in need of
psychological care

19. Conclusion
“The problem of underdiagnosis and
undertreatment cannot be remedied by simple
provision of guidelines and protocols, no matter
how elegant; it will require a reordering of the
actual structure and process of primary care.”
deGruy, F.V. (1997). Mental healthcare in the primary care setting:
A paradigm problem. Fam. Syst. & Health 15:3-26.

20. Models of Collaboration Between Primary
Care and Mental Health Care Providers
Level One: Minimal Collaboration - Providers in
Separate Locations
Separate systems
Rarely communicate about patients
Most private practices and agencies
Handles adequately problems with little biopsychosocial
interplay & few management difficulties
Handles inadequately problems that are refractory to treatment
or have significant biopsychosocial interplay

21. Models of Collaboration Between Primary
Care and Mental Health Care Providers
Level Two: Basic Collaboration on Site
Separate systems but share same facility
No systematic approach to collaboration - do not share common
language or in-depth understanding of each other’s worlds.
Misunderstandings are common
Common in mental health settings
Handles adequately problems with moderate bio-psycho- social
interplay requiring occasional communication about shared
patients
Handles inadequately patients with ongoing and challenging
management problems

22. Models of Collaboration Between Primary
Care and Mental Health Care Providers
Level Three: Close Collaboration in Fully Integrated
System
Same site, same vision, and same system in a seamless
web of biopsychosocial services
Staff committed to biopsychosocial systems paradigm.
In-depth understand of each other’s roles/cultures.
Operates as a team - regular collaboration

23. Models of Collaboration Between Primary
Care and Mental Health Care Providers
Continued...
Level Three: Close Collaboration in Fully Integrated System
Fairly rare. Occurs in some hospice centers and special
training and clinical settings.
Handles adequately most difficult and complex
biopsychosocial problems with challenging management
problems
Handles inadequately problems when resources of health
care team are insufficient or when there is breakdown with
larger service system

24. Somaliland/Somalia
Mental heath integration
into primary health care
There is poor primary health care
level at MCHs and hospital
facilities.
Mental health services are not well
developed and there is no
integration at this time.
Somaliland has one of the highest
mental health disorders prevalence
worldwide.
.

25. Global efforts
In 2008, WHO developed the
MHGAP curriculum guide for the
low and middle income countries.
Several countries have now
adopted it for primary care
physicians.
Amoud medical school will give the
guide as part of mental health
undergraduate teaching in January
2012.

26. MH Gap Guide
addresses
Depression
Psychosis
Schizophrenia
Mania
Alcohol and substance misuse
Suicide
Assessment sheets
Cognitive disorders

27. Mental health and
physicians
Primary care physicians don’t have
mental health education after
leaving medical school.
Primary care physicians meet with
psychiatric patients suffering from
co-morbid medical conditions.
Some try meds usually without
psychiatric assessment

28. Psychiatry in Borama
There was psychiatric reference till
before 2011.
Physicians were not interested in
mental health as general.
Psychiatric service was not
existing.
Patients were not taken to
hospitals as there was nothing for
MH

29. How we can address
mental health
Integration of MH into primary
health care
Referring hard cases into
psychiatric practice.
Workshops and CME on mental
health for physicians

30. Somaliland
Somaliland mental health service
is restricted.
Mental health ward is located in
Hargeisa now run by GRT
Former prison in Berbera is the
mental hospital in Berbera
Mental health OPD and inpatient
ward in Burao
Mental health OPD in Borama

31. Other towns in Somaliland have no
mental health services.
Traditional healers centers named
centers of care receive so many
patients they use herbal
medication, beating and residential
rooms to keep patients in.
No mental health policy
No mental health integration policy
yet.

32. Mental health education
Amoud and Hargeisa medical
schools have their undergraduate
curriculum developed.
Given in the sixth year by the
King’s College London in support
with THET.
Distance learning support in
mental health teaching for medical
students , interns and junior
doctors on
www.medicineafrica.com

33. Amoud mental health
teaching
Dr. Jibril Handuleh developed OPD
for mental health teaching and
patient care.
Dr. Handuleh is also Somaliland
coordinator for medicineafrica.
The teaching is offered for nurse
and medical students since April
2011.

34. Case presentations, class room
teachings and community mental
health service is given in Amoud
This service is also introducing
mental health gap curriculum into
Somaliland mental health
education for medical students.

35. Puntland
Mental health services in

Bosaso

Galkacayo

Garowe
Traditional healer centers exist
No medical schools
Most of the work is done by GRT

36. South/central Somalia
Mental wards
Traditional healers
Dr. Habeb center is the most
common mental health ward in
Mugadishu.
Some are scattered in places like
Marca etc.
Refer the WHO mental health
situational analysis, Feb, 2011

37. No undergraduate psychiatric
teaching and online support
compared to Somaliland.
THET and King’s College only
operate in Somaliland.
Given the civil war, famine and the
refugees , the problem is much
bigger in the south/central Somalia
compared to relatively stable
regions.

38. Mental health in Borama
Borama had two hospitals at the
end of 2010 with no mental health
service.
Both hospitals are teaching
hospitals for Amoud University
school of health sciences.
Students had no site for psychiatric
bedside teaching.

39. Amoud Mental health
project
Amoud University started mental
health project in Borama.
The medical school asked Dr.Jibril
to come with the mandate to
develop a mental healith service.

40. Students were going to Hargeisa to
have mental health teaching as a
part of undergraduate teaching.
The faculty was interested to
develop mental health OPD first to
offer patient care and clinical
bedside teaching.

41. Jibril, a former mental health rep
ended internship in November
2010.
Amoud University recruited Jibril
as clinical teacher next month.
I was already Pathology lecturer
and clinical assistant in Psychiatry
as part of mental health rep post in
both Amoud and Hargeisa medical
schools

42. Background of Amoud
mental health service
Due to the high demand for
psychiatric patient care and clinical
teaching , it was necessary to
develop a service.
Jibril agreed to come up with
service development plan.

43. Mental health service
To introduce mental health in
Borama a pilot project had to be
developed to

Learn mental health pattern in
Borama

Raise public awareness for mental
health care.

Create suitable environment for
student mentoring and supervision.

44. Mental health and global
partnership
Pilot mental health project had
been in partnership with King’s
college London , Institute of
Psychiatry-UK and tropical health
and educational trust.
Pilot phase was coordinated with
GRT, Italian NGO working in
mental health in Hargeisa, Berbera
and some parts of Puntland

45. Peace ware Somaliland and ICT
department of the University of
Copenhagen, Denmark.
in later stage , started link with
EMRO mental health and
substance misuse department.
Huge technical input from
Keroniski institute of Sweden’s
Psychiatrist Dr. Yakoub Aden Abdi

46. Mental health project
components
Hospital OPD at Alhayett teaching
hospital
Prison mental health
Community based psychiatry
MCH related Perinatal psychiatry
School psychiatry

47. Hospital based service
The only option available was the
development of OPD department
as there is no ward in Borama.
Ward is currently being planned in
Borama and will take time to
develop.
Outpatient and emergency case
management

48. Hospital rotation
Saturday and Wednesday were the
two days allocated for OPD.
Work was from 7.30- 2 P.M
Classes for nurses in the last six
months
Classes for med students in the
coming 8 months continuously.
Intern mentoring

49. Patient care at the OPD
Integrated into medical OPD
Patients receive free consultations
Patients are offered medications-
Poor patients only.
Follow up of patients
Patient education with dedicated
patient education leaflets
Good documentation system

50. Telephone number support in case
of emergencies
Working with 2 local NGOs to refer
patients for treatment
Link with local volunteer networks
bringing in patients

51. Patients both in the
general practice and the
MH OPD

52. Student benefits
2 day bedside teaching
Strong clinical supervision
Student log books
Student assessment sheets
2 whiteboards for teaching
Teaching materials in place
Student exam preparation and
implementation with KCL faculty.

53. Teaching OPD nurses
and student nurses-CPD
session

54. Achievements
250 patients in the OPD were
received in the hospital OPD
alone.
The patients had been receiving
free medication and consultations
with mental health service.
Patient follow up scheme was
successful as 90% of patients
came up with follow ups.

55. Community psychiatry
This is the first community based
psychiatry in Somaliland.
it has two components

A. home visits

B. traditional healer link

56. The community
program…
Home visits segment is the
cornerstone part of Borama based
psychiatry.
Amoud nursing school and
concerned citizens are major
partners.
Home visits come through demand
and service provider commitment.

57. Home visits
Patient home visits take place
almost daily at any time possible.
A doctor and a nurse always go to
homes.
Telephone follow up exists to trace
the cases down.
Local pharmacist was trained to
help give depots and educate
patients

58. Traditional healers
Traditional healers link was
established in a desire to reach out
patients.
Patients were kept in a house with
three Sheikhs using so many sorts
of herbal medicines.
They also use water boarding and
beating.
In the last visit even chaining pts.

59. Partnership
They agreed upon referring cases.
They call our service to provide
mental health assessment and
management.
Mental health service follows up
patients after discharge.
My work reduced their stay days.
Stronger follow up to encourage
mental health service

60. Perinatal psychiatry
Introducing mental health into the
maternal care was crucial in our
program.
It is first program again to have
such program in the Somaliland.
It has antenatal and Postnatal
components in partnership with
Amoud nursing school.

61. Global partners
King’s College London, UK with
Perinatal psychiatrist working with
me on this.
University of Cape town school of
Medicine- South Africa. Technical
and academic input in the
development of teaching materials.

62. In the pilot phase
Training the trainers in Perinatal
Psychiatry in both antenatal and
Postnatal care setting in Borama
MCHs
It includes

basic assessments

Common Perinatal psychiatry
presentations

Referral systems

Follow ups

63. Training program
Nursing tutors
Borama MCH workers
It was done in July , 2011
Referral system was introduced
Program will start in January 2012
MCH patients with mental illnesses
will be referred to psychiatry
practice at the teaching hospital.

64. Prison service
The first of its kind in Somaliland.
The program has the following
partners

Somaliland ministry of Justice

Somaliland Custodial corps

Amoud Legal Clinic

Borama prison

Amoud University

65. Objectives of prison
service
Train prison guards on mental
health problems among inmates.
Advocate for patient care and
treatment
Treating for free inmates with
mental illnesses
Training the prison nurse in basic
psychiatric practice
Developing referral system

66. Achievements
Over 30 inmates treated
Training for prison guards done
within three months through
tutorials and on job case scenarios
Referral system is in place
In partnership with Amoud legal
clinic , the service offers forensic
consultation with Borama court.

67. School mental health
service
Again , a major step forward with
mental health in Somaliland.
In a study , 19 suicide cases in
Borama were related to untreated
depression. Handuleh, J. untreated
depression among high school
students in Borama, North
Somalia, Arab journal of
psychiatry, to be published in May
2012.

68. School mental health
service
Schools had no formal health
system.
Mental health was not even
existing.
Students and teachers suffer from
whole sort of mental and
neurological problems

69. Amoud University contacted the
local ministry of education office.
The plan was presented
Ministry of education approved the
project involvement in schools
The project started to work with
school teachers, student union
leaders and the headmasters.

70. Students received patient care at
schools. The headmaster of
schools turned into outpatients
working with parents.
Al-Aqsa school presented with
school children.
The other schools will receive the
same student assessment and
management

71. Mental health workshop
for teachers
• It was set to be in July but schools
went into holidays.
• The workshop will take place in
Mid December.
It will have the following objectives:
Teacher training in school mental
health arena
Communication skills and student
support
Identification and referral systems

72. Lessons learnt
Mental health development is
dynamic and very interactive.
Patient care improved patient life
and family
Community gave huge input and
appreciation
Local NGOs , citizens alike were
very encouraging.

73. Global partnerships
Teaching service development
Community inputs from prison to
homes.
Creating research potentiality
Faculty support, GPs and other
players in Amoud University

74. Challenges
Human resources
Community based barriers
Financial issues
Time management

75. Opportunities
Creating leaderships in mental
health among med/nurse students
and then at the intern level.
Reaching out villages through
visits and nurse education at
remote places.
Using Skype and 3G technology in
the future.
MANY MORE!!!

76. Any questions

77. Thank you very much!